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MI
Motivational Interviewing
Jassin M. Jouria, MD
INTRODUCTION
Motivational interviewing (MI) is a method that promotes behavior change,
and can be used in a multitude of environments and situations to foster
growth and to help people to take on challenging situations. Motivational
interviewing is a collaborative process that edifies the client and makes him
or her responsible for personal choices. It is not necessarily a stand-alone
type of therapy, but instead can be incorporated into treatments and routine
care for clients with various health issues, including those with physical
health problems, mental health issues, or substance abuse and addiction. MI
has also successfully been used along with other forms of therapy to
improve connection between the client and the provider and to alter the
process at which the client makes changes in his or her life.
Therapists can use motivational interviewing in a number of situations, yet it
should always be recognized that no one could be forced to change.
Although the goal of MI is not to directly change a person’s behavior, it does
guide the client toward making different choices that can foster change in his
or her life.
The concept of motivational interviewing began in the early 1980s with the
publication of a book by William R. Miller, PhD, who focused his model of MI
on working with people suffering from substance abuse and addiction. The
book was titled Motivational Interviewing with Problem Drinkers and it was
initially used among psychiatrists and other professionals who provided
counseling services for people going through treatment for addiction [5].
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Almost twenty years later, Miller and a colleague, Stephen Rollnick,
published a second edition of the book. The second edition was geared, not
only toward addiction professionals working in the field of psychotherapy, to
any professional in the healthcare field who could utilize the principles and
put the techniques of MI into practice with their clients [5].
Miller and Rollnick described motivational interviewing as a “directive, clientcentered counseling style for eliciting behavior change by helping clients to
restore and resolve ambivalence” [5]. Ambivalence is a state in which a
person is uncertain about which direction to take, if any. A person who feels
ambivalent about his or her need for change or required treatments may
approach the situation with a lack of motivation. The person may have such
mixed feelings about the situation that making a decision can be paralyzing.
When a therapeutic relationship starts, the client may be in various stages of
ambivalence depending on the current situation. If he or she was recently
diagnosed with an illness or disease, ambivalence may be paired with
frustration or anger over the situation. Alternatively, the client may have
known for quite some time that change is necessary but has been unwilling
or unable to take steps to move forward.
Motivational interviewing is more than just a set of techniques that can be
implemented into conversations between healthcare providers and their
clients. It recognizes several theories as a basis for its approach, including
cognitive dissonance theory, which acknowledges that a person who acts
against his or her beliefs will be motivated to either change behaviors or
otherwise justify them; and self-perception theory, which is the idea that
people conclude certain traits or ideas about themselves based on observing
their own behaviors [33].
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A basic premise exists in motivational interviewing that talk can be helpful
for some situations, but without the motivation to change, talk, or simply
telling a person to do something, will not get very far. The provider who is
working with a client through motivational interviewing must recognize the
level of motivation the client holds and must be willing to work through
possible resistance to change in order to foster goal setting and to move
forward [33]. Motivational interviewing can be used in many different types
of specialties for helping clients to change. Although it may be considered a
therapeutic approach that would traditionally be used in counseling or in
sessions with a psychologist, motivational interviewing can actually be a part
of some routine meetings or examinations for brief sessions.
Motivational interviewing has been used successfully in implementing change
in numerous situations, such as with drug or alcohol addiction, smoking
cessation, vocational rehabilitation, criminal justice, pregnancy, and as a
component of treatment for many different medical conditions [29].
Similarly, motivational interviewing is not simply designated for counselors
or psychologists. It can be successfully implemented into appointments or
interactions with various healthcare providers, including nursing staff,
primary care physicians, nurse practitioners, or allied health professionals.
There is some formal training available in developing the techniques
associated with motivational interviewing, although learning the techniques
and the process of MI is typically either integrated into formal education
programs, or through stand-alone training opportunities, such as through
workshops, conferences, or online educational programs.
The Motivational Interviewing Network of Trainers (MINT) is a non-profit
organization that was started by a group of MI practitioners who were
originally trained by Miller and Rollnick in MI techniques. MINT promotes the
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use of motivational interviewing, as well as continuing research and
appropriate training of practitioners. The organization is composed of
independent trainers and practitioners and can give details about specific
educational opportunities for those who want to learn more about
motivational interviewing and to put its methods into practice [30].
STAGES OF READINESS FOR CHANGE
The ultimate goal of working through motivational interviewing is to move
the client through the various stages of change, from being ambivalent or
unmotivated to dealing with unhealthy behavior and making more positive
choices [21]. The stages of readiness for change is actually a cycle of steps
identified by James Prochaska, and each step requires various interventions
to move the client on to the next step. The stages of change include:
precontemplation, contemplation, preparation, action, maintenance, and
termination [21, 22].
The precontemplation stage occurs before the client is even aware that a
change needs to happen. Family members, friends, and significant others
may easily recognize that the client has a problem or that change needs to
happen but the client is often unaware. During this phase, the client is
resistant to change because he or she does not understand its necessity. The
client may even be aware that life is difficult or there are several aspects of
life that demand attention that he or she cannot handle, but the concept of
change is still foreign.
The contemplation stage is when the client recognizes that a change needs
to happen. It is often at this stage where motivational interviewing begins.
Although the client may recognize the need for change, he or she may be so
ambivalent about making the change or what steps to take that no change
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occurs at all. Many people remain in the contemplation stage for years,
always feeling that something needs to be done, but never taking steps to
do anything.
The preparation stage involves planning to make a change soon. People in
this stage may still be ambivalent about what to do, but they are planning to
try for a change. They may be uncertain that their plans are the best for
solving their situation and so may still be somewhat ambivalent about
making choices toward change. They often need to convince themselves that
change is necessary and that their plans are the best method of working
through the problem.
The action stage involves taking the steps to overcome the problem. It is
during this stage that the client does a lot of activity that demonstrates
working toward the change, such as quitting smoking or exercising more.
Others can see the client’s work toward the change as well, which can be
encouraging. This stage also requires the most energy to continue with
changes, even if they are uncomfortable.
The maintenance stage is the ongoing phase that may be life long for some
people. This stage occurs after a person has done the work of making
changes but then needs to continue to make efforts to maintain the results.
For example, a person who has lost 50 pounds needs to maintain the weight
loss by continuing with efforts that he or she implemented to lose the weight
in the first place. If the person does not maintain the work, he/she may gain
the weight back.
The termination phase is one in which the initial issue is no longer a
problem. Some people never reach this phase while working for change, as
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the principles they developed and the work they completed must continue to
be maintained and reinforced for the rest of their lives. For others, the
termination phase results when the initial change or struggle is no longer a
problem and they can move forward into other activities without
continuously maintaining their previous efforts [22].
Key principles
Motivational interviewing can be broken down into key principles, followed
by significant processes that are used. Each process or principle is then
supported by various therapeutic techniques. Each technique may serve to
uphold or meet the goals of one or more principle or process throughout the
interview. To start, motivational interviewing consists of four key principles
that guide practice, which are empathy, discrepancy, rolling with resistance,
and supporting self-efficacy [5].
Empathy
Motivational interviewing is characterized by empathy on the part of the
provider. Without empathy, no amount of discussion, sympathy, or
understanding will stir the client toward change. The client needs empathy
from the provider in order to feel as if he or she is not alone in the process
and to feel that someone truly understands. Knowing that someone else has
empathy can reduce feelings of isolation and can spur change.
The goal of being empathic is to help the patient to feel that he or she can
open up. The caregiver provides an open and non-judgmental attitude that
conveys warmth. The provider’s demeanor when engaging the client should
express unconditional acceptance whereby the patient senses the provider’s
response to them to be:
“I know what you are going through; I care about what happens to you”.
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The provider during motivational interviewing does not try to change the
client’s ambivalence or condemn the situation. Rather, ambivalence should
be accepted as part of the process and the provider should expect that the
client would have those feelings. If not, then the motivational interview
would not otherwise be necessary. The provider should instead look at
ambivalence on the part of the client as the reason for their time together
and go forward from there.
Discrepancy
Discrepancy describes the state the client is currently in compared to the
point at which he or she wants to be. The clinician works through the
motivational interview to help the client see not only where he or she is
currently, but to remind the client of their goals. The client must understand
that these are two different states. The state where he or she currently is one of ambivalence about a situation requiring change - is not the same as
the state where he or she wants to be. If it were, the client would not be
working through the motivational interview [6].
To best help the client develop discrepancy the clinician assists the client to
see how far he or she has come in other areas of success. The clinician may
point out other areas of change such as by saying to the client:
“remember when you used to struggle so much with this?
Look where you are now and how much you have achieved in that
area.”
It can be helpful for the client to know that he or she has overcome
ambivalence or past challenges to reach goals in other areas and can know
that it can be done in this area as well.
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It is important for the clinician to remember that the practice of developing
discrepancy requires a non-judgmental attitude. The clinician should also
remember to ask before giving advice, and to speak clearly and in a
supportive tone. Clarifying those items that do not make sense may also be
necessary and is often an ongoing part of the process to avoid
misunderstanding. By utilizing these techniques, the client will be better able
to have a clear direction and understand where he or she is at in a process
of changing behavior versus where the client wants to be at the conclusion
of the motivational interviewing process [6].
The provider incorporates these key principles throughout the process of the
motivational interview. Instead of being a straightforward path, MI is a
somewhat fluid method that uses these principles as a general direction. The
provider may also use other processes as part of motivational interviewing
that support the initial principles discussed. These processes are: engaging
the client, promoting change by supporting self-focus, determining the
client’s motivation for change, and formulating a plan [6].
Roll with Resistance
While working with clients through the process of change, there are bound to
be times of resistance. When the provider discovers that the client is
resistant to ideas, suggestions, or change overall, it is important to take it in
stride and not create further tension; in other words, to roll with it. The
provider should avoid responding in a manner that is harsh or critical, even
if the client presents this type of demeanor.
Often, the idea of change can be threatening and some people may respond
negatively out of fear. Even if this is the response of the client, the provider
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should work to remain calm and to continue with the relationship, providing
the most support and direction possible through conversation. When the
client starts to become upset or resistant to the MI process, it is a signal for
the provider to slow down, avoid being forceful in any way, take a deep
breath, and consider how their demeanor and delivery of information is
presented to the client.
The provider should consider his or her words, questions, and any types of
non-verbal communication that could be threatening to the client and make
adjustments as necessary. The provider should then determine how he or
she can best present an empathic presence and show more understanding
toward the client to prevent further resistance. It might be necessary for the
provider to use some specific phrases during the interview that can clarify
what the client is trying to say and to defuse the situation as necessary. For
example, the provider could say:

“I hear what you are saying and I just want to make sure that I am
understanding you correctly.”

“That must be very difficult for you; I can’t imagine how hard it is
for you.”

“It sounds as if you want to consider other options for dealing with
what we are talking about.”
By responding differently, and not mirroring negative attitudes or behaviors,
the provider prevents the conversation from unraveling and prevents the
client from turning away from making changes because of feeling threatened
or otherwise resisting the motivational interviewing process [6].
Support Self-Efficacy
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Self-efficacy defines how a person feels about his or her abilities. It differs
from self-esteem, which describes how a person feels about themself and
their value as part of society. Instead, self-efficacy is the personal selfconfidence to perform a task or to take on a situation. A person may have a
strong sense of self-efficacy in one area of life but be weak in another. For
example, a client may be strong and confident at his job and may be quite
successful as a leader at work; however, the client may also lack selfefficacy when struggling with alcohol use and may be ambivalent about
change if they feel unable to overcome the struggle [11].
Although high levels of self-efficacy feelings may help a person to feel more
confident in his or her pursuit of a goal or involvement with a certain
activity, having self-efficacy does not necessarily guarantee that the person
will succeed [11]. A provider may work with a client to help them feel more
positive about personal abilities, but unless realistic goals and techniques for
achieving those goals are introduced into the equation, the client may still
not succeed when trying to change. Self-efficacy requires motivation and
effort to be successful.
A person’s belief that he or she can accomplish a goal works as a powerful
motivation toward change. Ultimately, it is the work of the client that
facilitates change, and not the provider. The client’s ability to make the
change, rather than requiring assistance or having a provider do the work
for them, further supports self-efficacy in the client because they know that
the accomplishment was achieved specifically by and for them. The
provider’s role is to be confident in the client’s ability to change and to
empower the client by asking questions and directing the discussion.
Engaging the client
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The goal of expressing empathy is to build a relationship of trust between
the provider and the client. Empathy involves accepting the client’s state of
ambivalence, even if the provider disagrees with the viewpoint. When the
provider takes on a non-judgmental stance toward the client, he or she
avoids being perceived as critical or otherwise condemning of the situation.
This stance engages the client and supports the development of a trusting
relationship.
A client who is going through a crisis or other situation that requires
motivational interviewing may already feel judged or criticized by others.
Many people who are in need of change are also aware of that need,
whether they can actually complete the change or not. For example, a client
who needs to lose a significant amount of weight in order to establish a
healthier lifestyle and to reduce the risk of developing certain health
conditions is most likely aware of the need for weight loss. Often, when
caregivers or the public judge or condemn others for their need for change,
it only serves to further diminish the motivation for change while
simultaneously causing negative feelings and disrupting self-esteem.
Therefore, a non-judgmental, accepting attitude must be in place on the part
of the caregiver before motivational interviewing even begins.
Expressing empathy involves considering the thoughts and feelings of the
other person by actually putting oneself into the place of the person. It
differs from sympathy, in which subjective information may allow a provider
to understand what a client is going through, but the provider can only
acknowledge the other person’s feelings as a method of providing comfort
[7]. Sympathy is not wrong in itself, but empathy can actually break down
potential barriers between the client and the provider by communicating
comfort and building trust through understanding. A client who receives an
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empathic response from a provider during a motivational interview may be
willing to open up more if he or she perceives that some of the struggles
involved are shared.
Determining self-focus
The focusing component of motivational interviewing involves setting up the
direction in which the conversations will go. It often starts with an initial
meeting in which the client and the provider meet to discuss their purposes
for talking and to discuss initial thoughts, concerns, or priorities of the client.
Through focusing, the provider takes the information given during the initial
conversation and helps the client to find a direction for where the
conversations will go [6].
It is important that the provider does not take complete direction with the
interview by telling the client what he or she should do. Part of the goal of
focusing is to allow the client to find his or her focus through the coaching
involved with motivational interviewing, not to be told what to do. The
provider should also avoid developing a premature focus in which he or she
decides the direction of the interviews early on [6]. This can limit the
potential for where the conversations could go and also impact how well the
client is able to work toward change. If the provider decides on the focus for
the client early on in the relationship, the client may be less likely to stay
motivated or involved, particularly if he or she believes that the point of the
relationship is only to work toward the clinician’s goals, not the client’s.
To develop a focus for the interview process and the therapeutic
relationship, the provider and the client should work together to decide what
the goals of their time together should be. By collaborating on the focus,
both the client and the provider have a vested interest in the relationship
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because they have worked together to set their goals.
Evoking change
The heart of motivational interviewing, according to Community Care of
North Carolina, is evoking change through the relationship between the
provider and the client. Evoking change involves helping the client to
determine his or her own amount of ambivalence toward the subject at hand
and the amount of motivation that he or she has to make a change [6].
Evoking change first requires understanding what the client wants to
change. This comes about through initial interviews, but may change
through the course of the relationship. If the provider and the client have
determined a focus for the MI, this will guide the provider toward where to
direct their discussions to evoke change. After the focus of the discussion
has been identified, the provider then helps the client to explore more
reasons for change, barriers to change, and what systems should be in place
to evoke change [6].
Before change can begin, the provider must also bring up and discuss the
client’s level of ambivalence. If the client is uncertain about changing or
which direction to take in order to make the change, the ultimate goals and
focus of the relationship may not go far if ambivalence is not addressed. The
provider should ascertain the amount of uncertainty the client is
experiencing by guiding the discussion. For instance, the provider may ask
the client some questions to explore any ambivalent feelings and determine
what might be keeping the client from taking a step in one direction or
another.
Change may be more likely to occur if the discussion focuses on past
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successes for the client. This focus can help to improve confidence and
feelings of self-esteem when a person knows that he or she has been
successful when attempting a previous activity [6].
The provider might focus on the client’s strengths at his or her job or in
other relationships and use those strengths to apply to the current situation.
For example, when considering a client who needs to lose a significant
amount of weight, the provider might bring up that the client has been
successful with committing to their duties at work and can stay focused on
them. The client may bring up past success with completing projects or
enduring through situations when circumstances were difficult. The provider
can then use that information to empower the client toward his or her next
goal of losing excess weight. By remembering personal successes, the client
can bring that information to mind the next time he or she struggles with
working toward a current goal.
It should be noted that not all relationships developed through motivational
interviewing evoke a complete change or result in change occurring at all.
Some people, despite being willing to enter into the motivational
interviewing situation and the therapeutic relationship, will be resistant to
change. Making changes, regardless of the underlying need, can be scary
and overwhelming and some people may ultimately decide that changing is
not worth it. However, it is important for the provider that utilizes MI to
understand that resistance to change does not have to be end of the
relationship. Instead, it should be looked at as an opportunity for redirecting
the focus of the relationship. The provider does not determine the path that
the client takes. Rather, the provider helps the client along the path that he
or she has chosen [5].
A final aspect of evoking change is preparing for the resources that will be
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needed to support that change. Typically, a client does not make changes all
on his or her own, and even with the help of a provider, long-term and
permanent change is not carried out without the help and support of others.
The client must learn about what resources are available and where to turn
for continued support. As these ideas are mapped out, the motivational
interview moves into the planning stage for how tasks will be completed in
order to achieve the desired goals.
Planning
The planning phase of the interview comes after much of the discussion
surrounding change has occurred, including discussion of the client’s
motivation and levels of ambivalence, his or her desire for permanent
change, and level of commitment to the change. Additionally, the provider
and the client have set goals for where to direct the interview in order to
best plan for the final outcomes.
Planning involves structuring how the process of the interview will take
place. The client and the provider work together throughout the process and
continuously re-evaluate how well the client is working toward set goals and
ideas for change. This may involve setting smaller benchmarks during the
process and providing little rewards along the way as the client makes
changes [6].
Planning also involves accountability between the client and the provider.
The client remains accountable toward the interviewer to keep him or her
updated about the work completed toward ultimate goals, the achievement
of smaller goals set along the way, and what resources have been utilized in
the process. This accountability allows for evaluation of what is working in
the process and what is not, and allows the provider and the client to work
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together to make changes where necessary.
Accountability is also required from the provider toward the client. The
provider must follow through with his or her plans for coaching the client and
commitment to the relationship. This involves keeping contact with the
client, following up on unfinished business, and maintaining that side of the
relationship to ensure that it will continue.
MOTIVATIONAL INTERVIEWING TECHNIQUES
Once the overall process of the motivational interview has been determined
and the healthcare provider is aware of the need for empathy, finding a
focus, evoking change in the client, and planning for resources, these
processes are facilitated through the conversation. The provider can use a
number of techniques to facilitate the interview, each with its own method of
supporting the processes that make up the therapeutic relationship.
Facilitating the process
The motivational interview typically begins with a meeting between the client
and the provider. Often, the first meeting is the first actual encounter with
the client, and the provider does not have much information into his or her
background. The provider may be aware of the need for the client’s change
because of circumstances understood in broad terms, but in order to
understand the client’s feelings of ambivalence as well as the greater details
of the need for change, the provider and client must have initial meetings to
discuss the client’s background and contributing factors for the relationship.
The initial encounter involves a getting to know you process in which the
client provides background information about him- or herself. Even at the
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beginning of the interviewing process, the provider must use techniques of
therapeutic communication to gather information and to establish a basis for
trust in the relationship. This involves active listening, avoidance of
interruptions, and reflection on what the client has said [5].
Once the background discussion has taken place, the provider can move
forward with the rest of the process of goal setting and evoking change by
utilizing various therapeutic techniques that are inherent parts of the
motivational interview. It is through these techniques that the client is able
to open up and provide more information, learn to trust the provider, and
work toward a mutual goal for the relationship. There are various techniques
that make up the motivational interview and can be utilized effectively to
support the different aspects of the relationship.
OARS
A technique that can be successfully used to engage the client, provide
empathy, and promote communication is known as OARS, which stands for
Open-Ended Questions – Affirmations – Reflection - Summaries. The process
of using OARS in communication can be looked at in the same way as a reallife method of using oars in a rowboat. Wagner and Conners clarify the use
of OARS this way: “[OARS] give us power to move, yet it is not a powerboat.
We don't zip from one place to another, yet with sustained effort OARS can
take us a long way” [8].
The provider uses open-ended questions to evoke more of a response than
simply “yes” or “no.” Although closed questions are sometimes necessary or
may be the only method of gaining some information, open-ended questions
should be utilized to get the client to share more information [8].
Sometimes, by starting to talk with answering an open-ended question, the
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client will continue to share much more. Open-ended questions are probing
but should not be too intrusive for the client, which can result in an opposite
effect. They demonstrate that the caregiver is curious about the client’s
situation and wants to hear more [6].
Examples of opening lines of open-ended questions that may be used in the
interview include:

“Tell me more about…”

“What did you do after…”

“Can you explain more about…”

“How did you feel when…”
Affirmations are the second section of the OARS mnemonic. Affirmations
look for successes from the client and point out those areas of
accomplishment. The provider must be genuine when providing affirmations,
as false praise is completely different than a genuine affirmation and a client
can usually understand when someone is not being authentic [5, 8]. If the
client does recognize that the provider is not genuine in his or her words, a
roadblock will quickly go up that is destructive to building trust and will keep
the client from sharing any more information.
Affirmations are words that are encouraging and optimistic; they are meant
to help the client see progress being made. Examples of affirmations that
could be included as parts of the interview are:

“I’m glad that you want to talk about this.”

“I think what you are doing would be very difficult, and you are
putting a lot of work into it.”

“You have made a lot of progress.”
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
“You controlled yourself well in that situation.”
The third component of OARS is reflective listening. This considers what the
patient has said and repeats it back to him or her in slightly different
language. The provider is reflecting on what the patient has said, while the
patient is listening to his or her own words said in a different way. This helps
both the provider and the patient. The provider uses reflection to fully
understand what the client is saying so that none of the information will be
misinterpreted. Reflection also helps the client to think about what he or she
is saying, consider its truth or inconsistencies, and clarify ideas that might
have been misunderstood.
Reflection should be a regular part of the motivational interview, as one
missed idea from one side or the other in the conversation can lead to a set
of false assumptions and misinformation that must be corrected before the
conversation can move on. Instead, regular reflection continues to provide
clarification for statements in a manner that is not threatening. Examples of
the openings of reflections that could be used in the interview include:

“What I hear you saying is…”

“It sounds as if you want to…”

“So, your concern is that…”

“You believe it is important to…”

“From your point of view, you…”
Summaries are the final component of the OARS mnemonic. Summarizing
takes the information the client has said and what has been discussed during
the interview and puts it into one or two concise statements. This process
has several purposes. It reinforces the idea that the provider is listening to
the client and has heard what he or she has been talking about; it serves as
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a type of reflection to help the client hear again what he or she has been
saying and to think about it; it clarifies information from the part of the
provider, and it provides a transition into the next segment, which could be
closing the session or moving onto another topic [6].
A summary of the discussion can motivate the client because it supports the
coaching provided by the provider. Summarizing also supports the focusing
aspect of MI in that the client is able to see a few distinct areas in which to
concentrate efforts, which can make the process seem less overwhelming
and may give him or her a better idea of how to focus tasks later on.
Examples of summarizing statements include:

“If we review what we have been discussing, I can see…”

“So, you believe that… Am I correct?”

“We have covered this information well by talking about…”

“Here are the points that I understand so far…”

“To summarize…”
Informing or advice giving
Providing information to the client and giving advice must be done very
carefully to avoid taking over the direction of the conversation and telling
the client what to do.
There will be many times when clients are impressionable: if they are
ambivalent about making a decision, they may want the provider to tell
them what to do. This is an important scenario to avoid, as the client needs
to process enough of the information in order to make his or her own
decisions. Additionally, if the client makes a decision based on what he or
she thinks the provider has said, there’s a risk the client may later regret the
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choice or may not be willing to stay with the outcomes and then feel angry
or blame the provider for suggesting the “wrong thing to do.”
By allowing the client to take their own direction and supporting them in
decisions, the provider helps the client to feel empowered by their own
choices and alleviates them of the role of being ambivalent to being more
decisive and goal-oriented. Information and advice should be open and
guiding, allowing the client to be the best expert for their own situation. The
provider always asks permission before imparting advice or giving
information about a situation, using statements or questions such as:

“Would it be all right if I shared with you…”

“I have seen this experience in the past. Can I tell you about it?”

“Could I share with you what I have read about this?”
It may be helpful at the beginning of the relationship to determine what the
client’s best method of understanding information would be. Some people
are visual learners and respond best to pictures or reading materials. Others
are auditory learners, and can take in and better grasp the information that
they hear. When the provider understands the various different types of
learning methods, he/she can be better prepared to share information in a
manner that has meaning for the client, such as by bringing reading
materials that support the topic of the conversation [6].
Giving advice, even when it is permissible, is not simply telling the client
what to do. Even if the client allows the advice, the provider should still
never direct statements to the client to say such things as, “if I were you, I
would…” or “you can fix this if you would…” Instead, the advice and the
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information must be connected to the client’s concerns and address those
thoughts and feelings. A menu of options offers choices to the client so that
he or she does not feel as if the advice or information given by the provider
is the only choice for the client’s behavior. Instead, providing a menu of
options as part of the information still allows the client to choose the best
step for him- or herself [6].
DARN CAT
A helpful mnemonic that can be used to elicit change is remembering DARN
CAT, which stands for Desire – Ability – Reason – Need – Commitment –
Activation - Taking steps. When a provider considers approaching the client
with talk about change, he or she can think of the DARN CAT acronym as a
reminder of how best to build motivation in the client.
Desire means a statement or words that the client uses that indicates
wanting to change. It is important to listen for desire statements, as the
provider can remember these and use them to remind the client at a later
time if he or she ever feels confused about their choices. Desire statements
are the beginning of resolving ambivalence: if a patient has a desire for a
change, he or she can at least understand the general direction in which to
go. Desire statements include anything that signifies the client’s wishes or
needs:

“I need to get my life in order.”

“I wish I could lose this weight to better care for my health.”

“I want my blood pressure levels to be normal.”
The A of DARN signifies the client’s ability to change, based on their beliefs
that change can happen by working with the tools and guidance available
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from the provider. The provider can better direct the client toward thinking
about items and successes that will support his or her abilities. The provider
might say:

“You were able to accomplish this before, is there something
stopping you now?”

“Why do you want to do this?”
The client also may also make statements that will signify that they have a
growing belief in themselves. These might be positive phrases or comments
that indicate that the provider has noticed the client has been thinking about
the change made and has grown in believing in themself:

“I’ve done this before; there is no reason why I can’t do it again.”

“If I can just….I think I can do it.”

“I can make this change if I work at it.”
The R in DARN stands for reason and explores the reasons behind the
change. The discussion may center on why it is important to change or the
disadvantages of not making the change. Exploring the reasons behind the
change also help to reduce ambivalence in the client because it provides a
clearer direction of change for the client. The provider can ask questions to
help the client better determine his or her need for change:

“Why do you think this change is important?”

“What benefit do you see happening from this?”
The N in DARN CAT stands for need. This step is important for the client to
better understand the true need for the change. Again, this step helps
resolve some ambivalence when the client is able to see how the problem
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affects his life and how making the change can improve the situation. Some
people become so involved with their situations that they fail to see how
destructive their lifestyles are. They may not be aware of the detrimental
effects of their choices or be able to see how change could make things
better.
For example, a provider might work with a client with a history of substance
abuse and who is working toward making changes in their behavior and
relationships with their family. The client may be so engrossed with
accessing and using drugs and alcohol that they do not understand the
impact that their behavior has had on their spouse and children. The client
may come to the situation feeling ambivalent about change or even unsure
whether the change is worth the time and effort. Over time, by discussing
the situation with the provider through motivational interviewing, setting
goals, and taking steps toward change, the client may be more likely to see
how much better life could be if he or she follows through with the changes.
The client better understands how truly important it is for them to change.
The client who starts to understand the need for change may make
statements that indicate his or her level of comprehension:

“I didn’t realize before how hurtful this all was.”

“I need to change so I can spend more time with my family.”

“I want to do things differently and try to mend my relationship
with my spouse.”
The first part of the acronym, DARN, is devoted to promoting change for the
client. Each of the letters in the word are focused on what the provider can
do to guide the client toward change, as well as how the client can recognize
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the importance of change and determine to make a difference. This is what
is classified as change talk and is the focus of DARN. Alternatively, the CAT
portion of the acronym consists of the second phase of mobilizing someone
toward change.
The C in CAT stands for commitment and signifies that the client is taking
steps to commit to change. This step is important to acknowledge because
verbalizing the commitment is the first step toward following through. If the
client can speak his or her intent out loud, it may become clearer and may
be easier to focus attention in the right direction. Examples of statements
that indicate commitment on the part of the client include:

“I will quit, because...”

“I plan to start…”

“I will finish…”
The A of CAT stands for the activation of the stated commitment. Once a
client commits to making a change, the provider and the client must work
together to determine how to best go about making such a change. If the
client is not equipped with the right tools for change, his or her words of
commitment will be meaningless. Examples of phrases from the client that
signify a readiness to activate the change include:

“I am ready for this.”

“I am prepared to change by…”

“I will work at this through…”
Finally, the T in CAT stands for taking steps, which are statements by the
client that confirm the readiness to change. These statements demonstrate
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the client’s commitment to change because they come from the client
instead of being directed by the practitioner. Because they are in the client’s
own words, the client has formed the suggestions for change into a
meaningful and realistic statement that he or she can now put into practice,
such as:

“I called my doctor to ask for a prescription for medication that will
help me quit smoking.”

“ I really had a craving for _____ earlier today, but I took a walk
instead.”
The implementation of the steps of DARN, followed by CAT, help the client to
understand the need for change and then take the important steps toward
completing interventions to reach his or her goal. Throughout the process of
working through the steps of the acronym, the provider should continually
evaluate the progress being made and make changes when something
doesn’t work. If the client resists one of the steps, the provider should take
a step back, clarify what is needed, and try to work through any gaps that
have presented as part of the process.
Elicit-provide-elicit
Another method of helping the client to take charge of his or her decisions is
the elicit-provide-elicit method. This idea serves to seek information from
the client, provide advice that can be helpful and empowering, and then
follow up with the success of the information. The elicit-provide-elicit method
is directed by the provider but is actually a collaborative process between
both the provider and the client.
The first elicit establishes the client’s expectations, beliefs, and goals of the
interaction or the change that is required. The provider approaches the topic
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with sensitivity and asks permission before giving advice or otherwise
directing the client. The provider may open with a question or a statement,
such as:

“Do you mind if we talk about…”

“Can I clarify something that you said about…”

“Would you like to discuss the subject of…”

“Can I share some related information about…”
Each opening phrase is designed to ask or clarify what the client knows
about the situation; it also asks permission for the provider to provide more
direction on the topic. The second step is to provide information about the
topic or to clarify something the client has brought up that still might be
unclear. The provider may say:

“This could be why…”

“What we know is…”

“Others have worked through this by…”
During the provide step, it is important to avoid using statements that
include I or you; and, to remain neutral. This avoids coming across as
judgmental or condemning in any way.
After providing advice or direction, the provider once again elicits
information from the client to determine how well he or she understands the
information presented and to get a better feel for how the information will be
used. The second step of eliciting involves more about the patient’s feelings
for the situation and how the information is interpreted. The provider may
say:
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
“What do you think of what we have talked about?”

“Where can we go from here?”

“How can I help you at this point?”
As with other interactions, it is important that the provider not tell the client
what to do during the second elicit phase or give his or her opinion about the
situation. Instead, it should be looked at as another opportunity to
collaborate with the client by using known information to work toward
results [5,10].
FRAMES
Another guide used to solicit change is termed FRAMES, which stands for
Feedback – Responsibility – Advice - Menu of options – Empathy - Selfefficacy. Following the FRAMES model approach during the motivational
interview can help the provider to remember the most important aspects of
interaction to foster success for the client.
Feedback involves the exchange of information between the provider and
the client. The provider may ask for information from the client by asking
open-ended questions and helping him or her to open up more with sharing.
The provider may also give feedback as part of reflecting or summarizing the
discussions and clarifying points. Alternatively, the provider may also offer
feedback to the client in the form of thoughts or advice.
An essential component of motivational interviewing is to always ask for
permission before offering advice or feedback on the client’s perspective.
This practice respects the client’s point of view and helps to address some of
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the client’s ambivalence about the topic [9].
The R of FRAMES stands for responsibility, which outlines some of the
expectations for the interviews as well as the responsibilities for change.
Ultimately, it is the client’s role to take responsibility for making changes
within him- or herself, however, the provider serves as a coach or director
for assisting with changes. The provider and client work together to
collaborate on the change process but the provider should direct the client
as to his or her expectations for change that they have decided on together.
It is not appropriate, nor is it possible, for the provider to take responsibility
for the client’s change; that responsibility must belong to the client.
Many providers who work with clients during the motivational interview
process are skilled and have knowledge of various psychological concepts
and therapeutic techniques that would be helpful to share with others who
need guidance for making changes in their lives. Giving advice can be very
helpful for some clients, particularly when they have enough ambivalence
about a topic of change that they are unable to make a decision about where
to begin. Just as with offering feedback, it is essential that the provider ask
for permission from the client before giving advice. This is a crucial element
of communication, as unsolicited advice is often not helpful and could be
misconstrued as looking to provide an automatic response, rather than
searching together to find the right answers for the client’s situation [9].
The menu of options refers to a list or group of choices given to the client for
making decisions. When a client is ambivalent about making a decision, it
can be easier when presented with more than one option of steps that could
be taken toward the goal. For example, if a client is trying to lower his or her
high blood pressure and is having difficulty adjusting to lifestyle changes,
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the provider could offer a menu of options to choose from to change, any of
which would contribute positively toward lowering the blood pressure. The
client could choose to lower salt intake by 500 mg daily, choose to increase
exercise activity to two 30-minute sessions each week, or could contact their
physician about starting another form of blood pressure medication. The
menu of options requires that a choice be made, but regardless of which
choice the client decides, they would each help to take a step closer toward
the client’s goal of better health.
Empathy refers to the method of engaging with the client to foster a trusting
relationship and to impact the client’s ambivalence toward making a change.
By being empathic toward the client, the provider is better able to
understand where he or she is coming from, but is also able to make a
connection on a deeper level. When a person feels that a provider truly
cares, a better sense of the degree of the client’s ambivalence may be more
evident and the client able to more likely to find direction toward the choice
that should be made. The provider can express empathy through their
statements and responses to the client by supporting what he or she has to
say and expressing understanding of the situation.
Self-efficacy is the final component of FRAMES; it refers to helping the client
understand his or her own strengths in the situation of change. The provider
can promote self-efficacy by talking with the client about his or her strengths
and accomplishments. This may mean bringing up past successes to use as
reminders and to promote confidence in the client. When a person believes
in themselves, they are much more likely to continue moving in the direction
of change, thereby reducing feelings of ambivalence. The client may be less
likely to feel overwhelmed or incapable of change if they believe in their
abilities and capacity for change.
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Pros and cons
Exploring pros and cons of a situation can be helpful in assisting someone
with making a decision. When a client experiences ambivalence about a
situation, he or she may not have enough information to consider potential
choices. Determining pros and cons of the situation can help to provide clear
direction for deciding on the next step of change.
Determining pros and cons is a relatively simple process. The provider can
make a list or chart of the client’s options, followed by an area to list the
pros, or the good aspects of the choice, compared to the cons, which are the
negative aspects of the choice. Listing the pros and cons helps both
the provider and the client to explore and discuss each of the terms.
Some people use the information from a list of pros and cons to go on to
make their decisions. They may look at the number of pros versus the
number of cons and decide based on sheer numbers alone. Alternatively,
while one side may have more than the other, the client may make a
decision of the pros and cons based on one or two aspects on the lists that
really stand out as being more important.
Non-verbal communication
Non-verbal communication makes up the posture, attitude, gestures, and
unspoken communication that both the client and the provider engage in.
The provider who is conducting the interview must be very cautious of his or
her non-verbal communication because it speaks volumes. Although the
provider’s words may be engaging and non-threatening, if the non-verbal
communication says otherwise, the provider will create the same impact as if
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harsh or critical words had been spoken.
Non-verbal communication supports the spoken word and helps a person to
remember what has been said. Alternatively, non-verbal communication can
convey certain messages all on its own. Facial expressions, eye contact,
posture and gestures all make up types of non-verbal communication.
A healthcare provider who is conducting a motivational interview should
display active listening when the client is speaking. Active listening ties
listening to the client with the appropriate non-verbal signals that show the
client that the provider is attuned to what he or she is saying. By actively
listening to the client, the provider not only hears the words with their ears,
but demonstrates other measures that shows the client that he or she is
being listened to, such as by leaning forward, making eye contact, and
nodding the head periodically [5].
Silence is another measure that may be implemented at the appropriate
time if the right non-verbal cues are paired with it. Often, people do not
necessarily like silence, believing that it makes conversations awkward.
However, if a client is sharing information that is valuable and personal, or if
he or she is experiencing emotions that can be overwhelming, the provider
can silently listen and wait while giving appropriate non-verbal cues. For
example, if a client begins to cry while talking about the death of their
father, the provider can sit silently with the client while they cry, allowing
them the opportunity to express grief. This silence can be much more
effective than trying to fill the space with words, interrupting the client while
they are emotional, or using automatic responses or clichés that are not
helpful.
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Facial expressions involve non-verbal communication that could be
overlooked during the conversation. At times, it may be difficult to maintain
an appropriate or neutral facial expression when discussing distasteful or
shocking information. It is important to maintain a positive or at least
neutral facial expression when talking to a client, rather than a look that
shows anger, disgust, contempt, or boredom, which will most likely be
noticed by the client and could break down some of the lines of trust that
have been developing.
If the client is demonstrating strong feelings, it may be appropriate for the
provider to mirror those feelings through facial expression. For example, if a
client is angry about a situation involving a colleague at work, the provider
may show anger as well to demonstrate that he or she understands the
strong feelings. Eye contact is another area of non-verbal communication
that sends a strong message. It may be difficult to determine whether eye
contact is appropriate in some situations, as there are some cultures in
which it is considered to be disrespectful or rude. Alternatively, for many
people, eye contact shows interest in the conversation, it demonstrates a
sense of openness from the provider, and encourages the client to continue
talking [7]. The amount of eye contact used is also important, as staring or
otherwise gaping at the client can put them off.
Posture can convey several messages, depending on how it is used. The
provider who wants to demonstrate openness and listening toward the client
should sit in a way that is leaning slightly forward with their hands in the lap
or at their sides. Alternatively, standing with the arms crossed in front of the
body demonstrates a closed appearance that is not easily approachable or
does not otherwise indicate a willingness to listen. Keeping the hands on the
hips may convey irritation or superiority, while tapping the foot or the
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fingers demonstrates impatience or irritation [7].
Many people display themselves through their posture with little thought to
how it appears to others. For example, a person who has self-confidence
may naturally walk upright with a straight back and look others in the eye.
Alternatively, someone who has low self-esteem or who is very shy may
have a slumped posture and may not make as much eye contact [7]. The
healthcare provider who is conducting the motivational interview should be
very aware of his or her own posture and how they carry themselves, and to
think about how it may come across to others. It may help to study one’s
own posture in a mirror or to ask others to comment or give feedback about
one’s posture and gestures to see if changes should be made before
interacting with a client.
LIFESPAN AND CULTURAL PERSPECTIVES
This section covers motivational interviewing in certain areas along the
lifespan and in varying cultural settings. Special focus is given in this section
to MI for children, adolescents and the older adult populations, and the
unique aspects of MI during the times of life where increased family support
is necessary and often crucial. A major development in the area of
motivational interviewing is in the area of child and adolescent care, where
youth require guidance in school and social settings. Its important for the
provider to realize that youth at all ages may have difficulties with change
because of the level of developmental changes they already undergo, and
the level and impact of their family support.
Interventions with children, in particular, during motivational interviewing
have been successful to some extent and are sometimes implemented by
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teachers and counselors that work with them at school. Children are often
more dependent on their parents and caregivers for support than
adolescents and typically have little say in what goes on at home. Therefore,
working with children through MI may need the added component of family
therapy and discussion to ensure that the families involved are supporting
the changes their children are experiencing [15].
Children and adolescents
Motivational interviewing can be used with children and adolescents by
helping them to explore their needs for change and address their feelings of
ambivalence about change. A provider who works with a child can determine
his or her readiness to change based on statements made about problems or
the need for change. It can also help the provider to determine the level of
motivation that the child has for making a change. The provider working
with a child needs to recognize the importance to maintain and convey an
attitude of respect for the child’s situation and for his or her own decision
about making a change. The provider must be careful not to take on a
parental role by directing the child toward what he or she should decide,
and, instead, continue with the appropriate coaching method that will help to
guide the child toward the right decision.
Because parents and families are typically responsible for managing the care
of children and the fact that young children are often not developmentally
capable to make certain decisions on their own, motivational interviewing
techniques are best used for children and their families to facilitate change.
The age at which to transition to working solely with the child to make his or
her own decisions is based on several factors, including the developmental
ability to rationalize cause and effect situations, such as: the understanding
that certain behaviors can cause negative effects; the child’s language skills,
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or ability to express feelings and address problematic behaviors; and,
understanding of the self, in which the child recognizes discrepancies
between their behavior and what they want to achieve. The age at which
these developmental concepts are achieved varies between children, but
often, working through MI exclusively with children without their parents
present does not occur until children have greater cognitive capacities for
change, which is closer to the age of adolescence [16].
Adolescence can be particularly challenging for many families, as the time
between childhood and adulthood is fraught with confusion, hormone
changes, and outside pressures that can make many teens feel uncertain
about themselves and may lead them to engage in potentially destructive or
harmful behaviors. From the standpoint of MI, adolescence is an important
time to discuss change and to recognize its power, as the time of
adolescence often sets the stage for future habits and lifelong behaviors.
Those activities that an adolescent participates in during the teen years can
impact health and behavior well into adulthood. Using motivational
interviewing as a method to reach adolescents can then change some
behaviors and help them to make better choices, not only for their current
lifestyles but for their futures as well.
Working with adolescents can be challenging, because the provider is faced
with developmental factors as well as addressing ambivalence and the need
for change. In addition to developmental changes, most adolescents live
with others in families that have a strong influence because of their ages,
and providers may need to simultaneously work with the teen through MI
and handle the actions or viewpoints of the parents or caregivers. For
example, a teen client who is going through motivational interviewing as a
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technique to lose weight may become motivated to change while working
through the MI process; however, the client may also have little to no
control over the types of food that is available at home because the client is
not responsible for grocery shopping, and may or may not be able to make it
to appointments consistently if dependent on others for a ride. If the parents
or major caregiver of teen clients that are undergoing MI are not on board
with the process, it can be much more challenging for the provider and the
client to work together to make changes that are consistent and lasting [12].
Practitioners who work with teens may need to work around many changes
that are occurring in these young peoples’ lives. These include biological
changes, such as physical growth, hormone changes, and puberty; cognitive
changes, including the development of more mature thoughts, ideas, and
concepts; and, social changes, such as developing a personal identity,
having friends and social relationships that may include pressure to change,
to fit in, increasing levels of autonomy, and living with family members [12].
Although all of these developmental changes greatly contribute to the
process and success of motivational interviewing, many practitioners also
find that working with adolescents is quite rewarding, despite its challenges.
Just as when using motivational interviewing while working with adults, the
provider and the teen client can start out in an individual session by building
rapport and investigating the levels of the client’s ambivalence. While
discussing the need for change and exploring ambivalence, the provider
must also look at discrepancies in the client’s behavior and desire for
change. Because teens can be impressionable and there are often greater
levels of confusion about the right way of behaving versus outside
influences, there could be larger discrepancies seen. For instance, a teen
who wants to have good grades at school and who states that this is
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important to him or her may also struggle with avoiding social groups that
want to hang out all weekend, avoid studying, and otherwise engage in
problem behaviors. This is a discrepancy for the client, who must choose
between what he or she says is important and what is actually done [13].
As with any interview, it is important for the provider to convey an attitude
of respect for the adolescent client. This may be difficult for some
practitioners who view adolescents in general as too malleable to be able to
make positive decisions for themselves. Before the interview even begins,
the practitioner must commit to respecting the adolescent client’s choices
and plan for change. The provider acts as a coach or guide during the MI
process and because many teens are impressionable, they may want
someone to make decisions for them or to assist them with deciding what to
do. There is a fine line to watch here to ensure that the provider does not
overstep their role to act as a parent or caregiver to the adolescent client
and make his or her decisions. Instead, the provider must always remember
to act as a coach and assist the teen client in decision-making, ultimately
allowing the decision to be the client’s choice.
The provider uses the principles of change talk with the teen client and
promotes self-efficacy for change in the situation. The other techniques
listed in this course can successfully be implemented with teen clients when
working through motivational interviewing.
One method that has been successful when working with teens in particular
is the use of group motivational interviewing, in which teens meet together
in a small group with a practitioner to go through the MI process together.
This may be challenging, as the provider must coordinate different opinions
and ideas from those involved to continue to coach and guide the group. The
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various viewpoints and struggles that come from each of the teens involved
may also be difficult to coordinate for the provider. The practitioner who is
facilitating the group must be able to recognize the individual levels where
each participant in the group is at and determine each member’s willingness
to change [14].
RAND has been working on an initiative to increase motivational interviewing
in groups for teens and has shown that the program is beneficial. The
approach uses small groups for interventions and employs the therapeutic
principles of promoting self-efficacy and expressing empathy. The groupcentered approach has been a positive activity for those involved because it
engages them with others who may be struggling with similar issues. It is
also validating for those who participate when they see other adolescents
with similar issues overcome and make changes in their own lives. [14]
Older adults
This section covers motivational interviewing in older adults and how it can
successfully be used as a means of facilitating change. The older adult
population should continue to be considered as a group worthy of continuing
change in life that leads to greater well being, despite the opinions of some
who deem older adulthood as a period of decline. Motivational interviewing
works well in the older adult population but typically must be reserved for
working with those who do not have cognitive disabilities [17].
The basic practices associated with motivational interviewing are the same
for older adults and the geriatric population as they are for working with
younger adults; evoking change through the principles of coaching and
guidance by the facilitator who uses empathy and who promotes selfefficacy. However, the provider must also recognize some challenges that
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can go with working among older adults.
Life expectancy is shorter when working among older adults and some may
experience a sense of hopelessness for the future as they age. Older adults
may also experience greater levels of grief from more frequent losses in
relationships or changes in circumstances; they also have more health
problems that develop because of the aging process and may be
concurrently involved with physical treatments or taking larger amounts of
medications [17].
Because of these changes that occur with aging, some modifications must be
made through motivational interviewing when working with older adults. The
provider may need a greater amount of flexibility with planning and goal
setting with the ambivalent older adult. This can include reviewing goals
frequently and re-evaluating the course of the interview on a regular basis.
Many older adults are resistant to psychological treatment and therapy and
attach a stigma to it; therefore, the provider may need to approach the
process of MI from a slightly different standpoint, offering MI sessions in
different settings, such as over the phone.
Other strategies may include repetition of information on a regular basis to
reinforce concepts and consulting with other providers who may be working
with the older client to manage other physical conditions, such as another
medical specialist who manages the clients health plan and prescriptions or a
physical therapist who has been handling some of the client’s physical
limitations [17]. Despite some of the added challenges associated with
pursuing motivational interviewing with older adults, working with this
population can be rewarding and satisfying for both the practitioner and the
client.
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Cultural influences
Just as it is necessary to consider the unique aspects of each person when
conducting a motivational interview, whether it be due to age,
developmental status, or change required in each situation, it is also
essential that the interviewer recognize the impact of cultural influences on
the interview process. A growing and increasingly diverse society requires
that the provider recognize the varieties of people and cultural backgrounds
that they may work with.
Providers must initially place value on diversity in order to keep an open
mind right from the beginning of the motivational interviewing process.
Throughout the process of interviewing, the practitioner must maintain an
awareness of the cultural preferences of the client and seek to not override
those practices with their own. The provider must instead approach the
process of change from the cultural perspective and preferences of the
client.
It may be difficult for the provider to have empathy for the client,
particularly when such cultural differences exist between the client and the
provider that it is hard to imagine a connection. The provider must
symbolically put themselves into the shoes of the client in order to practice
empathy; this requires a greater understanding of the client’s cultural
preferences before understanding how to do that. For instance, consider a
situation in which a practitioner is working with a client who is religious and
engages in regular prayer as part of making changes. Alternatively, the
provider does not have the same beliefs as the client and does not consider
the impact of prayer in their own life when making personal changes. How
might the practitioner practice empathy in this situation if he or she does not
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share the same beliefs as the client?
Although the provider cannot compare themselves in the exact same
situation as the clients because the provider does not have the same beliefs,
he or she should take a slightly broader perspective when trying to be
empathic in this situation. The provider may not believe in the power of
prayer in the same manner as the client, but may believe in something else
that is powerful to them and that worked to help them to make changes in
their own life. The provider can then consider the significance of these items
in their own life when showing empathy to the client. It is not that the
provider and client share the same exact beliefs, but they can both
understand the significance of certain practices that influence change. That
connection is where empathy is able to develop and where the provider can
genuinely find the link between him- or herself and the client.
In addition to being empathic toward the client, the provider must also
express empathy in a genuine manner so the client understands the
empathy and does not feel judged. A client who is seeking help through MI
for making changes may already feel condemned in some ways because of
the need for change. A client with a significantly different cultural
background from the practitioner may feel even more threatened if he or she
feels judged because of personal beliefs or cultural practices. It is imperative
that the practitioner be empathic toward the client in a manner that is
genuine and honest [18].
Because promoting self-efficacy is a key component of motivational
interviewing, the process of reaching the point of confidence in making
changes for the client may differ between individuals with varying cultural
practices. Some people do not value self-efficacy as much as others, which
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makes the concept a difficult one to teach. Additionally, factors such as
poverty, immigration, or gender roles can impact a person’s sense of selfvalue or feelings of self-efficacy. For example, a person who has lived in a
refugee camp for years before eventually working through MI to make
personal changes may have little value for feelings of self-efficacy when he
has had to spend years simply trying to survive. There may be a range of
feelings about self-efficacy and its value within different cultures.
When a client places low value on self-efficacy because of cultural influences,
the provider may need to work more with the client to explore the reasons
behind this and to come up with solutions that will help the client to continue
to work toward change. According to Burke, et al., there are four states that
contribute to self-efficacy in a person: mastery experience, vicarious
experience and modeling, social persuasion, and physical and emotional
states. A person’s background through experiences and social influences
impacts their level of confidence and self-efficacy [19]. If the provider
recognizes these influences, he or she can use some of their time with the
client to support the value of self-efficacy as a positive step toward change.
This may take longer and more in-depth study of the client’s background
and perceptions, but is worth the effort to connect with the client in a
manner that will support his or her self-confidence and provide direction
where ambivalence may exist.
In order to successfully work with clients of differing cultural backgrounds,
the provider must start by being aware of his or her own cultural beliefs and
how they may differ from those of others. If the provider is secure in their
own beliefs and preferences, they may be better able to work successfully
with others who are different, as they will be less likely to feel threatened or
challenged. Examining one’s own beliefs first before starting to work with
clients is foundational for the provider starting the motivational interviewing
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process. The provider can then function in their practice with recognition of
the various differences in individuals and to value and respect the levels of
diversity that are present in the population.
PREGNANCY AND MI
Motivational interviewing has been used successfully among pregnant clients
who need to make lifestyle changes in order to improve their own health and
that of their baby. MI may be an option for soliciting change among
pregnant women in order to help them make healthy choices, such as
following a healthy diet and engaging in regular exercise. It can also be used
among some women who must make changes because they struggle with
substance abuse or are smokers, both of which can cause health problems
and increase the risk of complications during pregnancy.
Pregnant clients may engage with members of the healthcare team who can
provide motivational interviewing and who are often in the role of counseling
or educating patients about pregnancy support. A client may have several
visits with a healthcare provider during pregnancy as part of routine prenatal
care. Regardless of whether a pregnant client needs assistance with
changing negative or harmful habits, motivational interviewing can be part
of regular contact with the client.
When assessing a client who is seeking routine prenatal care, the provider
may open the conversation by first seeking rapport with the patient,
explaining their own role in the healthcare system, and identifying what type
of services are provided that the provider can help with. This presents an
open invitation without committing the client to any specific activity or
change.
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If the client agrees to accept the services and participate in MI, the provider
can then move to ask about the best ways to help the client. For example,
the provider may say:

“How best can I help you at this time?”

“What services are you looking for?”
These are open-ended questions that elicit longer explanations from the
client, which can help the provider to better explore the direction of the
services needed. As the client is answering, the provider listens intently,
using body language that conveys an open and caring attitude. All of the
provider’s responses indicate empathy toward the client’s situation. If there
is a time when the client does not know what to do, the provider can help
her to narrow down possibilities to better guide her toward making a
decision. The provider should first ask permission, and then may say
something such as:

“Can I explain to you some of the services we offer here?”

“I can answer any questions you might have about your
pregnancy.”

“Are there any educational offerings you might be interested in
learning more about, such as breastfeeding or the childbirth
process?”
By offering a menu of options for the client, the provider gives suggestions
for areas of focus without actually making the decision. These offerings help
the client narrow down areas of content to focus on and ultimately, to make
the decision herself.
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Once a client makes a decision about the focus of her care during
pregnancy, the practitioner and client then work together to successfully
incorporate the steps needed to accomplish the goals. Regular re-evaluation
of the client’s level of motivation, the need for services, and any issues or
problems that have developed should be done throughout the process with
the goal of getting the client through a healthy pregnancy by guiding her to
take care of herself [20].
Unfortunately, some women who are pregnant make unhealthy choices or
engage in activities that can be detrimental to their health and can risk
harming the baby. Substance use, such as alcohol, drugs, or smoking
cigarettes can increase the risk of complications for the mother and fetus
and may cause problems during labor and delivery. The American College of
Obstetricians and Gynecologists (ACOG) supports the use of motivational
interviewing to affect change among women who are pregnant to promote
positive behavior choices [21].
Motivational interviewing can be a part of regular routine prenatal visits for
pregnant clients or, if a problem has developed during pregnancy, such as
the identification of substance use, it can be a stand-alone objective in which
the provider and client sit down together to discuss the client’s choices and
their effects. When MI is incorporated into routine prenatal visits, the
provider could be someone such as the physician, the nurse, or the nurse
practitioner that is managing the client’s care. Adding MI to a regularly
scheduled appointment adds little time to the overall encounter, but the
results can be significant. According to ACOG, the process of active listening
and motivational interviewing during a visit only adds approximately three
minutes to the total time spent at the appointment [21].
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Motivational interviewing can be incorporated into many discussions and
topics that are covered through prenatal appointments for pregnant women.
Most pregnant patients go through a course of appointments in which the
mother’s and the baby’s health are evaluated during the time of pregnancy,
with prenatal visits coming more often as the estimated date of delivery
draws near. The physician or nurse practitioner caring for the patient
typically orders routine lab work, such as a test for gestational diabetes,
tests to check rubella status, or a complete blood count.
Other tests can rule out the presence of certain diseases during pregnancy,
such as tuberculosis, HIV, or other sexually transmitted diseases.
Additionally, the mother’s weight is monitored with each visit and other
areas that could potentially cause complications are checked routinely as
well, such as blood pressure readings. These aspects are monitored regularly
to assess for changes.
The results of many of these tests and procedures could point to an area in
which a pregnant client needs to change. For example, consider a client who
has just discovered that she is pregnant. She has her first prenatal visit,
where her provider orders routine labs and checks her weight and blood
pressure. Over the course of the next 3 to 4 months, the patient’s weight
increases at a rate that is much faster than what is normally expected during
pregnancy. The provider tries to discuss the appropriate amount of weight
gain during pregnancy and the patient starts to understand the necessity of
keeping her weight under control.
During many of the client’s next visits to see her provider, her healthcare
team, including the nurse or physician, can use motivational interviewing to
guide the patient toward change by eating a healthy diet, increasing her
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activity levels, and monitoring her weight at home. Through this process of
MI at regular visits, the client may move out of ambivalence and toward a
better lifestyle that involves controlling her weight and taking care of herself.
ACOG has reported that motivational interviewing has been effective in a
number of areas among pregnant clients, including reducing fears related to
childbirth, reducing the amount of alcohol consumption, smoking cessation,
increasing education and promotion of breastfeeding after delivery, and
limiting risky behaviors that can lead to sexually transmitted infections [21].
When clinicians specifically work with women who use alcohol during
pregnancy, intervention through motivational interviewing is extremely
important to prevent the development of fetal alcohol spectrum disorders
(FASD). FASD is a range of conditions that can develop with alcohol use
during pregnancy and can cause growth problems, central nervous system
abnormalities, behavioral issues, and problems with everyday functioning.
These problems are noted after birth and continue throughout the child’s
lifetime. FASD is preventable with eliminating exposure to alcohol, which is
why proper identification and intervention among pregnant women who use
alcohol is so important [23].
A provider who works with pregnant clients can assess for those who are
high risk by using the FASD Clinician Toolkit developed by ACOG to identify
those at risk and to intervene using motivational interviewing techniques to
guide these clients toward change. According to ACOG, a multicenter study
conducted on pregnant women who were engaged in risky drinking
behaviors showed a 70 percent reduction of risk in having an alcoholaffected infant six months after engaging in motivational interviewing to
educate them about the dangers of alcohol during pregnancy [23].
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After determining who would benefit from motivational interviewing for highrisk behaviors during pregnancy, the provider can spend some time with the
client to discuss unsafe behaviors and the effects on the fetus. The interview
should not be long and could be incorporated into a routine prenatal visit.
ACOG uses the FRAMES approach to demonstrate how to proceed in the
discussion [23]:

Feedback
Provide information and data to the client about the effects of
alcohol use on the developing fetus. In some situations, the client
may not be aware of the dangers of alcohol consumption during
pregnancy.

Responsibility
The client needs to be made aware that she is responsible for
herself and the health of her baby and it is up to her to make a
choice about using alcohol while pregnant.

Advice
After asking permission, the provider advises the client about what
she can do to avoid alcohol and the positive effects that can happen
when she makes healthy choices.

Menu of options
The client receives a list of options to consider for changing her
risky behavior or for how to find other alternatives to using alcohol
when it is used as a coping strategy.

Empathy
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Throughout the exchange, the provider conveys a sense of empathy
and understanding for the client, recognizing the difficulties in
making a change.

Self-efficacy
The provider helps the client to become more confident in herself
by taking charge of her health and knowing she is taking better
care of her unborn baby. By promoting self-efficacy, the client may
be more likely to commit to the change and maintain healthy
behaviors through the rest of her pregnancy.
After the MI process in which the provider addresses the problem behavior,
regular follow-up visits are necessary to ensure that the client maintains an
understanding of the importance of change. If the patient is demonstrating
changes at the next visit, the provider should be supportive of her progress
and encourage her to continue, regularly checking up with her to see if she
is following through. If the client is attempting to make changes but is
unable to carry out the work, the provider and the client should explore
these reasons together to determine if there are other methods of achieving
the same goal that the client could implement more easily. If the client is
unwilling to change, the provider should continue to work with her through
motivational interviewing to come up with solutions for change, making
referrals to other professionals as needed.
SMOKING CESSATION AND MI
Smoking tobacco is a leading cause of chronic disease and death throughout
the world. People who start smoking cigarettes have a very difficult time
quitting the habit because of the addictive properties of nicotine, which is
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found in tobacco. Nicotine has been shown to be as addictive as some illegal
drugs, such as heroine, and people who smoke on a regular basis or who
have smoked for many years become physically dependent on the nicotine,
resulting in symptoms of withdrawal when trying to quit.
Many people also become emotionally dependent on cigarettes, choosing to
smoke in certain situations, such as during social interactions or as a source
of comfort. They may have a difficult time quitting not just because of the
physical withdrawal from the nicotine, but also because of the psychological
impact that smoking has on their lives [25].
Smoking impacts almost every part of the body, causing damage to cells and
resulting in acute or chronic diseases that can ultimately become life
threatening. It worsens respiratory illnesses and causes a chronic cough, it
can lead to other lung diseases, such as chronic obstructive pulmonary
disease; and, it can also cause changes in the circulatory system that can
increase the risk of heart disease, hypertension, and stroke. Additionally,
smoking tobacco increases a person’s risk of certain types of cancer and can
cause complications with pregnancy among women who are pregnant and
who smoke [25].
Many people are aware of at least some of the dangers associated with
smoking, although not all people want to quit. Of the people who do want to
quit, many try to stop again and again without making a lifelong
commitment to stop.
There are many products and options on the market available to people who
smoke and who would like to quit. Studies have shown that both
pharmacological approaches and behavioral interventions have helped
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people to stop smoking. Pharmacological interventions include some types of
medications that can reduce the craving for nicotine, while other
interventions include nicotine replacement that slowly decreases the amount
of nicotine taken in by the body over time until the dependence is minimal.
Alternatively, behavior mechanisms for quitting smoking range from
hypnosis to cognitive-behavioral therapy, to group therapy, to motivational
interviewing. MI has been used successfully with many patients to take steps
to change their lives and quit smoking permanently.
A study by The Cochrane Collaboration looked at the positive impact of
motivational interviewing to promote smoking cessation. The study
considered whether MI was successful in promoting smoking cessation when
compared to routine care or no advice. The study showed that the effects of
MI are long lasting when compared with other forms of therapy; intensive
sessions of MI that are longer in time or in number of sessions are more
effective than single sessions; that people who quit smoking while using MI
have similar long-term outcomes of relapse when compared with people who
quit smoking while using other therapies, and that there are no adverse
effects from using motivational interviewing [24].
The study was a meta-analysis of work done by using motivational
interviewing for smoking cessation that examined randomized controlled
trials for results. The studies used the principles of motivational interviewing
as part of smoking cessation programs, including promoting change through
self-efficacy, exploring ambivalence, and assessing the clients’ motivation to
quit [24].
The study results showed the positive impact of motivational interviewing by
using a non-judgmental and non-confrontational approach that improved
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self-efficacy among patients who were trying to quit smoking. The sessions
that were at least 20 minutes long were more effective than short
interventions, and most clients needed at least two, if not more sessions, in
order to be successful in their attempts at quitting. The motivational
interviews were successfully held in various settings, including general
practice healthcare offices, outpatient settings of hospitals, through
telephone conversations, or in clients’ homes [24].
A motivational interview session could develop in several different ways,
depending on the client’s initial desire to change and to quit smoking. The
interview evolves as the provider engages the client and each learns more
about the client’s level of ambivalence toward quitting, as well as other
factors that may be prominent, including resources available to help with the
change, level of resistance on the part of the client, and even the connection
and compatibility between the client and the provider. Because there are
various factors that can affect the motivational interview, no two interviews
will be alike. However, it is possible to anticipate varied directions that a
motivational interview could take with the goal to support smoking
cessation.
The provider should begin with establishing rapport with the client, making
introductions, and orienting the client to the purposes of the motivational
interview [26]:
“Hello, my name is _____ and I am a therapist here at the clinic where
we are meeting today. I thought we could talk about healthy lifestyle
practices to better help you know how to stay healthy and feel good.
Many people who smoke cigarettes eventually develop health problems
associated with their heart or their circulatory systems. They can also
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become addicted to cigarette smoking because of nicotine, a substance
found in cigarettes. You may or may not have these issues, and maybe
you feel quite healthy. I would like to get your opinion about cigarette
smoking and its effects on health.”
The opening is friendly and it establishes the provider’s role and level of
education, which may be something that establishes even a greater level of
trust for the client. The provider also does not start out with telling the client
about the hazards of smoking and then recommending that he or she quit to
avoid having similar outcomes. Rather, the provider is non-judgmental and
open to the possibility that the client does not have current health problems
and instead would like to discuss his or her tobacco use.
After an initial discussion that involves the client’s opinions about cigarette
smoking, the provider can then move on to determine the client’s level of
ambivalence about quitting. The client may give many clues during the initial
sharing of opinions regarding smoking in the first place, but it is important to
determine what level the client is currently at when considering the
plausibility of quitting for good. The provider can give further feedback or
make requests for more information, or she may clarify what the client has
already said.
To provide feedback or request more information from the client, the
provider might start with:

“Tell me about your tobacco use.”

“What do you think of the effects of nicotine on a person’s body?”

“Do you think smoking could cause harmful effects to you?”
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If the provider wants to clarify some information given by the client, she
might use some of the examples or phrases that the client has said:

“What I hear you saying is that you believe smoking is harmful to
your health.”

“So, your family member died as a result of smoking and you don’t
want the same thing to happen to you.”
As the provider continues to assess the client’s readiness for change and
level of ambivalence about quitting smoking, he or she should continue to
use words that reflect empathy, ask open-ended questions, and encourage
the client to do a lot of the talking. Frequent reflection or re-evaluation of
what the client has said is often necessary to continue to clarify important
points and to ensure that the conversation stays on track to avoid
misunderstandings [26].
Finally, at the end of the initial discussions, the provider should summarize
what the client has said:
“To summarize, you have talked about how you know that smoking
cigarettes is harmful to your health and you would like to quit, but you
do not know how to get started. You are afraid that if you do no quit,
you will develop a disease similar to your family member’s condition
and you could die from that. You feel that you have been smoking for
so long that it would be impossible to quit now.”
The next step of the process moves the client toward change. The provider
has assessed the client’s level of ambivalence and now should emphasize his
or her talk on finding reasons for change, rather than maintaining the same
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behaviors. After the initial discussion, the provider may determine that the
client is resistant to change, wants to change but doesn’t know how, or
wants to change and is ready to move forward. The following example might
be one in which the client wants to change but doesn’t know what to do
next.
“To go forward from here, you have told me that you have been a
smoker for fifteen years and you think it would be extremely difficult
to quit at this point. However, you have also said that you would like
to quit to benefit your health. What other reasons can you think of that
might be a benefit of quitting smoking?”
This conversation supports the concept of discrepancy, in which the client
sees the difference between where he or she is now and where she wants to
be. By listing other reasons for quitting smoking in addition to improved
health, the client verbalizes other measures that support his or her need for
change. The next step might be to ask the client about his or her level of
interest in quitting:

“Based on the reasons listed, do you think you should continue to
smoke?”

“You have discussed why you know smoking is harmful, what can
you think of to do about your smoking habit?”

“May I give you some more information? I think you know why it is
important not to smoke and you want to quit, but…”
This discussion places the responsibility for change in the client’s hands.
After starting with a foundational conversation about the importance of
quitting smoking, the provider comes to the point where he or she must
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determine if the client will change or not. This determination then helps the
client to know if they should move forward to setting goals and finding
resources for quitting or if they need to revisit the discussion about the
detrimental effects of smoking. If the client has agreed that he or she should
play an active role and take responsibility for quitting smoking, the
discussion with the provider can continue [26].
Once the client has committed to making a change, the next step is to
identify those steps that the client should take to work toward that change.
The provider and the client should work on identifying those steps together.
In some cases, the client who is trying to quit smoking may not be aware of
his or her options for taking steps to quit.
Education is a component of this step, and the provider
should give information that can be useful to the client, delivered in a
sincere and empathic method. An example would be:
“I think you recognize that it is important to quit smoking and you are
ready to take steps to quit. Let’s talk about some options that you
have for moving toward your goal of smoking cessation.”
A menu of options provides the client with alternatives for how best to
approach quitting smoking. For example, the provider might give the client a
list of methods, such as using nicotine replacement patches or undergoing
cognitive-behavioral therapy; contact numbers for support groups and
organizations that may be of assistance or may provide support and help, or
a referral to a healthcare provider to prescribe medication that can help with
reducing nicotine cravings. The provider could introduce options to the client
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in the following way:
“I have a list of options that might be available for you to consider.
Let’s talk through each of these so you can better understand the pros
and cons of each and then you can decide if there are one or more
options that you could implement into your lifestyle to help you quit.
Once you decide, we can then see how to get started with putting
these into place.”
Once the provider has gone through the menu of options for the client, he or
she should ask the client which option works best for their situation. If the
provider encounters resistance, they should back up and talk through the
client’s decision to quit and then try to discuss the options again, acting as a
guide for the client instead of simply telling him or her what to do. Other
topics to explore might be obstacles or barriers that could develop that
would prohibit the client from making a permanent change or the return of
ambivalent feelings that would prompt the provider to revisit the client’s
level of motivation [26]. The level of motivation could be explored with such
statements as:

“Are there any issues you see that would stop you from putting
these interventions in place?”

“Do you feel that you can take the next step and [place a phone
call/contact a provider/ask for a prescription] to help you get
started?”

“Do you feel that if you implement these interventions, you will be
better able to meet your goal?”
Finally, as the meetings draw to a close, the provider should continue to
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summarize and clarify in order to evaluate the effectiveness of the
discussions that have taken place. Regardless of whether the client plans to
change and quit smoking, the provider should thank the client for taking the
time to talk about the issue involved and for at least considering a change in
behavior. If the client decides to move forward with making a change toward
quitting smoking, the provider must affirm this and help the client know
what to do next [26]:
“We have talked about the importance of quitting smoking to you. You
have said that you have smoked for a number of years and you know
it will be difficult to quit. However, you also have had a family member
pass away due to illness caused by smoking and you do not want the
same thing to happen to you. Thank you for taking the time to discuss
your concerns about smoking with me. We discussed a number of
options that you can consider that can help you to quit and you have
decided to try nicotine replacement therapy through the patch system.
This sounds like an option that could work very well for you and you
could incorporate it into your lifestyle.”
At the end of the discussions the provider should follow up with the client to
determine how well the options are working and to see if the client needs
assistance with any other issues. The client may have tried the options
discussed but then found that they did not work out and may need further
direction. Alternatively, the client may report that the situation has improved
dramatically and he or she has been able to successfully quit smoking.
Whenever a client agrees to make a change in his or her lifestyle as a result
of motivational interviewing, someone should follow up to determine if other
needs have occurred or whether the MI sessions were successful in helping
to bring about and maintain change [26].
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ADDICTIONS AND MI
Motivational interviewing has been successfully used with patients suffering
from substance abuse. The original work published by Miller in 1983 in the
early stages of MI was targeted toward working with patients who had
difficulties with alcohol addiction. Motivational interviewing continues to be a
successful intervention when used among some patients who want to stop
drinking alcohol.
A study by Lundahl and Burke, which included a meta-analysis of 119
studies that examined the effects of motivational interviewing when working
with patients with varying issues showed that motivational interviewing was
at least as successful as other forms of therapy when compared with other
types of interventions, and was significantly successful when compared to no
treatment for alcoholism [33].
Substance abuse differs from addiction, although the two scenarios can
cause difficulties for the involved client and loss of relationships with others.
Substance abuse involves using a substance, often alcohol or some type of
drug, in an inappropriate manner, such that it becomes disruptive to normal
activities of daily living. Substance abuse interferes with responsibilities,
such as those of going to school or work, maintaining a home, or providing
childcare.
Despite the problems that the use of substance causes, people who struggle
with substance abuse continue to use, often with negative consequences.
For example, a person who is struggling with substance abuse may use
alcohol inappropriately to the point that it impacts his abilities to work or
take care of family. The person’s spouse and other family members are
aware of the problems caused by the alcohol use, but the person continues
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to drink despite efforts to talk or convince him or her otherwise [56].
Alternatively, substance addiction causes problems for the person abusing
the substances and also causes a dependence that typically requires using a
larger amount in order to achieve the same effects. The person also
experiences withdrawal when trying to stop using the substance, and may
have made efforts to cut back or stop entirely without success [56].
Non-substance addictions, which may also be referred to as behavioral
addictions or impulse control disorders, are those situations in which a
person engages in an activity that produces some type of reward and
continues to do the activity despite adverse consequences [57]. People who
struggle with non-substance addictions may have great difficulties resisting
the urge to perform an activity and may continue to do so on a repeated
basis, which is often similar to substance addiction. Also similar to substance
addictions, behavioral addictions cause a great amount of pleasure for the
person performing the activity, which then may be followed by feelings of
remorse, anger, or helplessness. Unlike substance addictions, behavioral
addictions do not cause symptoms of physical withdrawal when the addicted
person stops performing the activity [57].
Examples of behavioral or non-substance addictions include pathological
gambling, excessive shopping, Internet addiction, or compulsive sexual
behavior. Patients who are addicted to these activities are at risk of
potentially severe consequences that can occur in addition to the alienation
and disruption to relationships that addiction causes. For instance, someone
who struggles with pathological gambling may be at risk of financial
difficulties through an inability to stop gambling, despite losing large
amounts of money at times.
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Motivational interviewing has been used among professionals working with
clients who suffer from substance abuse and addiction. The process can be
implemented through counseling and alongside other treatments, such as
pharmacologic therapy, to help individuals with substance abuse disorders
make choices for their health and play an active role in managing their
diseases. Because the provider in the interview collaborates with the client
instead of taking on a paternalistic viewpoint, the partnership of working
together through MI can help the client focus on his underlying need for
substance use that resulted in addiction [58].
Motivational interviewing also works in use with clients with both substance
addictions and behavioral addictions because the change is not forced and
the client is guided to come to their own conclusions about what or how he
or she wants to change, based on their level of motivation. This
empowerment puts the responsibility for change on the client and the
provider is not an authority figure, but, rather a coach or guide helping the
patient recognize this process.
The main principles of MI support this process. For instance, when a provider
is empathic toward the client who struggles with addiction, the client is less
likely to feel judged or cornered. A person with a substance abuse problem
who seeks treatment often already has a plethora of issues to face and
overcome and putting him or her with a provider who is critical of personal
choices will only derail the process of help and change. Instead, an attitude
of empathy by the provider helps the client feel that someone cares about
them despite their personal mistakes and background [58].
When the provider acts as a guide, he or she helps the client to better see
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the errors in some of their ways and the value of making changes. The client
may seek care coming from a situation full of hurt and regret, with feelings
of shame, hopelessness, or despair over an inability to stop whatever
activity is causing the addiction. The client may be angry that life is not
different or that the choices he or she has made have only led to confusion
and trouble. Regardless of the client’s feelings about their addiction, if they
are willing to work with the provider to consider change through motivational
therapy, then the client can see the discrepancy between where he or she is
now (heartache, pain, confusion) and where he or she wants to be (a life of
greater self-control, freedom from addiction).
12-Steps programs
Many people have found help from substance abuse and addiction by going
through 12-step programs such as Alcoholics Anonymous (AA). The idea
behind AA is to be a membership group where people who struggle with
alcohol use and addiction can meet with others for support and help for their
drinking. Alcoholics Anonymous meetings may have speakers or people may
share their experiences and challenges with using alcohol in order to
facilitate discussion.
The AA program is based on 12 steps that each person works through in the
process of handling alcohol addiction. Some of the 12 steps cover ideas that
the person is powerless over alcohol, believes in a power greater than
themself that he or she can turn their life over to for help with alcohol, has
made a moral inventory of themself, has admitted to themself and to others
the level of wrongs that they have committed, and has asked God or his
higher power to remove those wrongs and shortcomings [88].
A benefit of going to AA and continuing involvement with it or any 12-step
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program that is used for help with substance abuse and addiction is that if
the person is truly incorporating the 12 steps into his or her life, it is
understood that he or she wants to change. In this respect, motivational
interviewing can be incorporated into 12-step programs to facilitate change
and better help people struggling with substance abuse or addiction to set
goals for change and feel empowered to move forward.
In some situations, change is mandated, and the client may or may not want
to give up using drugs or alcohol. For instance, a situation in which a patient
is required to attend counseling for drug abuse as part of a sentence for a
criminal offense may only put the patient in a place where he grudgingly
goes along with therapy. In these types of situations, motivation will be
quite low and motivational interviewing may not be successful. Alternatively,
in situations where the client is willing to take steps to change and has a
sincere desire to give up the substance for the good of him- or herself and
others, MI can be incorporated into treatment [87].
DIABETES AND MI
Motivational interviewing has successfully been used in targeting patients
who are at risk of developing diabetes as well as those who have already
been diagnosed. There are modifiable risk factors for diabetes that, when
implemented, can significantly reduce the risk of developing the disease.
Motivational interviewing can help some patients to recognize their risks of
developing diabetes and to take steps to change their lifestyle habits
to minimize these risks.
Alternatively, people who have been diagnosed with diabetes can still
practice many activities that contribute to health and wellbeing and that
reduce the risk of complications associated with the disease. Motivational
interviewing can challenge these patients as well, to help them understand
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the importance of healthy living through diet, exercise, and blood glucose
maintenance to control their disease [27].
Diabetes is a condition in which glucose levels in the bloodstream are too
high. Normally, the blood glucose levels rise following a meal, as foods are
broken down and digested. The body responds to this rise in blood glucose
levels by secreting the hormone insulin from the pancreas, which acts to get
the excess glucose out of the bloodstream and into the cells where it can be
used for energy. This process provides energy to the cells and fuel for the
body, and it also regulates blood glucose levels, which can be damaging
when they remain consistently high over a period of time [28].
Diabetes is further broken down into two main types: type 1 diabetes, which
used to be referred to as juvenile diabetes because it was consistently
diagnosed in childhood for many patients; and type 2 diabetes, formerly
known as adult onset diabetes, because it often developed during adulthood.
Today, type 1 and type 2 diabetes can develop in people of any age,
although type 2 is more common and has many more modifiable risk factors,
including being overweight and obese.
Type 1 diabetes often develops as a result of an autoimmune process in
which the body attacks the cells in the pancreas, affecting its ability to
produce insulin. The body then cannot keep up with insulin production
needed to regulate blood glucose levels and glucose remains consistently
high in the bloodstream. Type 2 diabetes develops when the cells become
resistant to the effects of insulin. The body may still secrete insulin through
the pancreas, but it is not as effective. The pancreas needs to secrete more
and more insulin to control blood glucose levels and it ultimately cannot
secrete enough to keep up with demands. This results in consistently
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elevated levels of glucose in the bloodstream as well [28].
Both type 1 and type 2 diabetes can cause significant complications that
impact a person’s ability to heal from certain diseases and can lead to
serious illness or even death. Diabetes is connected to heart disease,
metabolic syndrome, kidney disease, blindness, diabetic neuropathy, eye
disease, and problems with pregnancy [28]. Being diagnosed with diabetes
requires lifelong maintenance of blood glucose levels, and often medications
and other lifestyle changes in order to reduce the risk of developing
complications. Clearly, it is important to manage diabetes as much as
possible upon diagnosis or to recognize risk factors in the lives of some
people to prevent its development in the first place to avoid considerable
loss later. Motivational interviewing can work with many patients at different
stages to recognize the various risk factors for diabetes or to better
understand the importance of managing the disease to maintain a healthy
lifestyle.
Motivational interviewing can work well as a form of lifestyle factor
intervention for clients who are at risk of diabetes. Pre-diabetes is defined as
impaired glucose tolerance (IGT), which is demonstrated by a glucose level
between 140 and 200 mg/dL upon undergoing an oral glucose tolerance
test; or impaired fasting glucose (IFG), which is demonstrated as a fasting
glucose between 100 and 125 mg/dL. People with IGT and IFG are at
significantly higher risk of developing type 2 diabetes and its associated
complications. However, studies have shown that instituting behavior
interventions among people with pre-diabetes, such as by using the
techniques applied through motivational interviewing, may reduce the risk of
pre-diabetes developing into type 2 diabetes [27].
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The Diabetes Prevention Program conducted a study that compared
therapeutic lifestyle changes with pharmacologic intervention in the
prevention of type 2 diabetes among patients diagnosed with pre-diabetes.
The study found that lifestyle interventions caused an overall reduction of
diabetes risk in 58 percent of clients when compared with a 31 percent
reduction in risk among clients who used metformin to control their risk of
diabetes [27]. Motivational interviewing, when implemented into care visits
or as a stand-alone effort for reaching people at risk of developing type 2
diabetes, can educate clients about the effects of implementing therapeutic
lifestyle techniques and can promote change among clients who may know
they need to reduce their risk of diabetes but who are uncertain about where
to begin.
For patients who have been diagnosed with type 2 diabetes, management of
the disease can be difficult not only to understand the process, such as by
checking blood sugar levels on a regular basis or calculating appropriate
carbohydrate counts, but there may be other constraints that prevent some
patients from implementing strategies to care for their health when they
have type 2 diabetes. Some patients raise difficulties with paying for
supplies or medications, and there may be time issues that prevent some
people from being able to check their blood glucose levels or determine
appropriate amounts of insulin to administer. As well, some people may not
have access to regular appointments with healthcare providers to maintain
contact and updates about their care [32]. Such factors can significantly
affect motivation for change among clients, which can be addressed through
MI.
One of the reasons why MI can be successful when working with patients
who have type 2 diabetes is that it is an individualized approach that
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considers the specific needs of each client’s situation. The method can
address issues that impact motivation in each client, rather than providing a
catch all method of giving generalized advice or using scare tactics [32].
An example of how each client is different in their needs and responses for
MI can be understood in terms of the reasons why each client would seek
help to control diabetes in the first place. Two clients with diabetes may be
separately seeking help; and, while one client may not have been successful
with managing their health because they cannot afford to pay for glucose
monitor strips every day, the other client may not have made changes
because they are simply afraid of checking glucose levels. During
motivational interviewing, the provider can address each of these issues
individually with the separate clients, helping each client to come up with
solutions that are specific to their challenging situations.
According to the Journal of Diabetes Nursing, motivational interviewing
techniques were successfully implemented into educating and treating
patients with type 2 diabetes. The study was known as the Diabetes Nurse
Case Management and Motivational Interviewing for Change (DYNAMIC).
The study was a randomized, controlled trial that separated participants into
two different groups: a control group that received standard care for type 2
diabetes and a focus group that received care for their diabetes using the
DYNAMIC intervention, which used motivational interviewing as a method of
evoking change in health behaviors among participants. All of the
participants involved in the study had type 2 diabetes.
The researchers conducting the DYNAMIC study found that nearly all of the
participants involved had other psychological distress or issues connected to
their type 2 diabetes diagnoses. The concurrent psychological findings
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ranged from depression related to a diabetes diagnosis and ongoing care to
feeling judged and policed about performing activities within a certain
timeframe, to lower levels of self-care behaviors related to anger or
frustration. The participants were all, therefore, at greater risk of poor
outcomes related to their diabetes control because of these additional
distressing circumstances. The study showed that participants who went
through MI as part of their treatment in the DYNAMIC group responded more
and had more beneficial health outcomes when compared with participants
who received standard diabetes care [32].
The participants who received the DYNAMIC intervention stated that they felt
more positive about their role in taking charge of their health, they did not
feel judged or policed for their behaviors but instead were met with
empathic and consistently caring responses from their caregivers that made
them want to cooperate more. Even in situations when lab results did not
show changes or showed that participants had slipped in their accountability
for change, the nurses performing the motivational interviewing remained
non-judgmental and were accepting, which enhanced trust and a greater
desire to cooperate from the participants [32]. Based on these outcomes, it
can be said that motivational interviewing certainly provides a positive and
healthy view of change that enhances in clients a motivation and desire to
take charge of their health.
Another study found in Diabetes Research and Clinical Practice also showed
that patients who participated in motivational interviewing as part of their
treatment for type 2 diabetes responded better to interventions when
compared to patients who received standard treatment alone. The study
divided groups into two areas: one that received standard treatments and
one that participated in motivational interviewing as part of treatment. All
patients involved had type 2 diabetes. Some of the patients were more
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responsive to MI techniques as part of treatment and were more likely to
respond to making healthy changes [31].
The patients who received standard care for their diabetes complained of
feeling judged and facing paternalistic and critical responses from their
providers. They often felt demeaned in their attempts to control their
diabetes. Alternatively, the participants who were in the MI group stated
that they had more positive feelings toward their treatment and received
care in a non-threatening and helpful manner. According to the study, five
themes emerged that participants commonly stated they felt was their
experience: nonjudgmental accountability, encouragement and
empowerment, being heard and responded to as a person, collaborative
action and goal setting, and coaching rather than critiquing [31].
Effective communication is necessary when working with diabetic clients who
often need to understand the seriousness of their disease. In many cases,
healthcare providers are more aware of the complications and the
complexity of diabetes than the clients and must communicate the
information accordingly. Rather than directing clients about what they need
to do and checking in to see if they have been successful in following
directions, the provider through motivational interviewing can instead work
alongside clients to provide information about the seriousness of diabetes,
the need for self-care and management, and the importance of regular
healthcare follow-up [31].
Through motivational interviewing the provider is able to provide the needed
follow-up to ensure that the client is making important changes and can
address those issues that are prohibiting change. Rather than taking a
paternalistic approach with diabetic clients, the provider through
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motivational interviewing demonstrates a more collaborative and successful
approach to help prevent some very significant complications among this
population.
HEART DISEASE AND MI
The American Heart Association (AHA) recognizes the importance of
behavior changes in improving heart health and has stated that behavior
changes are an important component of reaching the AHA’s 2020 goals,
which includes “improving cardiovascular health of all Americans by 20
percent while reducing deaths from cardiovascular disease and stroke by 20
percent” [40]. Cardiovascular disease, also referred to simply as heart
disease, is actually a range of conditions that can affect and compromise the
work of the heart. A number of conditions that affect the heart and blood
vessels can be classified as heart disease, including coronary artery disease,
heart attack, cardiomegaly, heart arrhythmias, and heart valve disease.
Coronary artery disease is one of the most common forms of heart disease.
It occurs as the result of plaque buildup in the coronary arteries, or the main
arteries that provide blood to the heart. Plaque deposits build up inside the
coronary arteries because of cholesterol and other substances, which
eventually narrow the inside of the artery and decrease blood flow. When
coronary artery disease develops, the patient is at higher risk of other
complications, including stroke, heart attack, and peripheral vascular
disease.
A significant danger is the formation of blood clots. If a clot forms at the site
of the atherosclerotic plaque or a piece of the plaque breaks off into
circulation, it can become lodged in one of the vessels leading to the heart
or the brain, causing a heart attack or stroke. Decreased circulation to the
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heart decreases its overall function and the function of major organs of the
body. Blood may not reach the distal extremities as quickly as it once did
and may result in pain in the legs when circulation cannot keep up with
activity.
If the atherosclerosis in the coronary arteries causes a complete blockage, a
portion of the heart can become deprived of blood. Without adequate blood
flow, the tissue in the area beyond the blockage becomes ischemic from lack
of oxygen and tissue death begins to occur. This is what happens with a
heart attack, which is a leading cause of death and disability among people
with heart disease [41].
Other types of heart disease can also cause significant complications for
patients and must be managed accordingly to avoid developing further
problems or disabilities. Cardiomegaly occurs as enlargement of the heart
muscle that often develops after the muscle tissue has been damaged. This
damage can be caused by impaired circulation due to coronary artery
disease or hypertension. As the heart becomes larger in size, it is not able to
pump blood as effectively, which further impacts overall circulation and
decreases the amount of oxygen reaching the tissues and organs [41].
A heart arrhythmia is an irregularity in the rate in which the heart beats.
Heart arrhythmia may occur as a result of coronary artery disease,
electrolyte imbalances, cardiomegaly, or injury that occurred from a heart
attack. When a heart arrhythmia develops, it can start in different areas of
the heart and may be erratic, fast, or slow. The condition can increase a
person’s risk of developing blood clots if blood does not flow properly
through the chambers of the heart and pools in certain areas within the
heart. A heart arrhythmia may also significantly disrupt circulation, which
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affects other organs and can reduce how much oxygen and blood is reaching
parts of the body.
Finally, heart valve disease develops when the valves between the chambers
in the heart do not function properly. They may have become stiff and
stenotic, or they may not close completely when they are supposed to. As
with some other forms of heart disease, blood flow can be impaired with
valve disease as well. If blood backs up because it cannot flow through the
heart chambers properly, it can cause heart failure (formerly called
congestive heart failure), which leads to fluid accumulation in circulation,
respiratory difficulties, and tissue edema [41].
Clearly, heart disease of any kind can be very significant, which is why so
many efforts are aimed at preventing, managing, and treating these
conditions. A number of lifestyle factors significantly contribute to the
development of heart disease, including being overweight/obesity, inactivity,
and smoking. Patients who are at risk of developing heart disease because
these lifestyle factors are a regular part of their lives or those who have
already been diagnosed with heart disease can all benefit from making
changes to incorporate healthier habits and either reduce the risk of
developing the disease or reduce the risk of developing complications
associated with heart disease.
Patients are at risk of heart disease when they are overweight or obese.
Overweight is classified as a body mass index (BMI) of 25.0-29.9, while
obesity is classified as a BMI over 30. It can be extremely difficult for some
people to lose weight and develop a healthy BMI, even with a diagnosis of
heart disease. Many people have become so accustomed to unhealthy eating
patterns, whether by choice of food because of taste, or due to other factors,
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such as financial concerns or the availability of cheap and unhealthy foods.
Regardless of the reason behind unhealthy eating, it is important that the
patient understands the need for changing food intake to employ choosing
healthier foods in moderately sized portions in order to reduce the risk of
heart disease. Motivational interviewing can help the client to work with a
provider to come up with solutions for problems with eating. For instance, if
the client is having difficulties obtaining appropriate foods because junk food
is cheaper than healthy food and he does not have a lot of money, the
provider could work with the client to come up with options for obtaining and
preparing healthier foods.
Dietary intake impacts the work of the heart as well as circulation. Reducing
levels of saturated fat and cholesterol, as well as controlling salt intake all
impact the risk of coronary artery disease and hypertension. According to
Franklin, et al. in an issue of Circulation, people who follow a healthy diet
similar to those who live in Mediterranean areas and who consume greater
amounts of unsaturated fats have up to a 31 percent reduced incidence of
heart disease [40]. Further, changing dietary practices to include decreased
saturated fat intake and decreased cholesterol intake may reduce plaque
size in atherosclerosis, thereby potentially improving coronary artery
disease [40].
Increasing physical activity has also been shown to improve heart health and
reduce the risk of cardiovascular disease and complications associated with
cardiovascular disease among those who have been diagnosed, with risk
reductions in up to 50 percent of cases of cardiovascular mortality [40].
Increased physical activity regularly increases circulation and strengthens
the heart muscle. The heart must pump faster in order to keep up with the
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demands of circulating blood to the tissues and the lungs when breathing is
increased due to exercise. Patients who increase their physical activity levels
may not only reduce the risk of heart disease and its complications, but may
also lose weight, have improved stamina, and may have greater feelings of
well being by participating in regular activities that are enjoyable.
Increasing exercise levels is also a change that could be taken on through
motivational interviewing. Patients who need to exercise more or who live
sedentary lifestyles may or may not be aware of the benefits of exercise and
the risks associated with a sedentary lifestyle. Motivational interviewing can
give a provider an opportunity to work with a patient to assess how he or
she feels about exercise and its benefits. After assessing the patient’s levels
of ambivalence toward exercise, the provider and the patient can work
together to set some goals for increasing exercise levels on a weekly basis, if
the patient is willing to make a change. For example, a patient with
hypertension is at risk of heart disease because of a high intake of saturated
fats and because of a very sedentary lifestyle. The patient may know that
exercise is important for some people but may not understand how it affects
the heart or why there is a need to add it to his or her life.
The provider can work with the patient to first help him or her better
understand the importance of exercise on heart function and to teach or
educate about how to incorporate more exercise into daily life. This
information is given in a nonjudgmental and non-threatening manner so that
the patient may be
more likely to respond positively. If the provider and the patient together
determine that change is important and the client is willing to work toward
change, the provider can then direct him or her toward programs or sources
of support to help to increase the level of exercise.
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Together, the provider and the heart patient may discuss which types of
exercise are most enjoyable or those that he or she could most easily begin.
They could talk about the minimum amounts of exercise needed to derive
benefits and then come up with ways to start slowly and increase to set
goals of regular activity. Motivational interviewing holds many benefits for
discussion and change talk to get a patient with a heart condition who needs
to exercise more for the sake of their health make positive changes.
Smoking cigarettes greatly contributes to heart disease and its
complications, and smoking kills 450,000 Americans every year. A study of
British physicians found that people who smoke shorten their lifespans by
approximately 10 years [40]. Although smoking causes harm to almost
every organ in the body, it can significantly impact the work of the heart and
the blood vessels, contributing the heart disease.
The chemicals that are found in cigarette smoke cause damage to the blood
vessels, which can impact how well they function. The decreased functional
capacity of the blood vessels further contributes to atherosclerosis and
coronary artery disease when the blood vessels are more rigid and blood
flow is less efficient. Smoking, when combined with being overweight or
obese and having a sedentary lifestyle, can significantly increase the risk of
heart disease and its associated complications [42].
As discussed in the section of this course related to motivational interviewing
and smoking cessation, motivational interviewing has helped some people to
quit smoking permanently. When a patient seeks help with their health
related to heart disease and the provider discovers that he or she is a
smoker, the provider can use the techniques of MI to discuss the situation
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with the patient and address their level of motivation about quitting to
support their health. If the patient is willing to take steps to quit smoking to
reduce the risks of heart disease and improve their lifespan, the provider can
then help the patient to find more resources to successfully quit smoking
permanently.
5 A’s of motivational interviewing
Counseling professionals have recommended the use of the 5 A’s when
working with some clients to make lifestyle changes in general. Motivational
interviewing can be used alongside the 5 A’s when its essential techniques of
empathy, rolling with resistance, discrepancy, and supporting self-efficacy
are followed. The 5 A’s include [43]:

Ask

Advise

Assess

Assist

Arrange
Through motivational interviewing, the provider can first ask the client
questions about him- or herself as a method of building rapport and trust
between the client and the provider. When using MI to support smoking
cessation, the provider also asks questions about the client’s tobacco use,
such as length of time spent smoking and the amount smoked.
The advice and assessment methods could be paired together if they are
presented in a non-judgmental manner and if the clinician asks for
permission before giving advice. For instance, the provider might say, “do
you mind if I tell you…” and then share what he or she knows about the
negative impact smoking has on heart disease. The assess step of the 5 A’s
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then determines the client’s level of motivation to quit smoking and make
better choices for his health. During the assessment phase, the clinician asks
the client outright if he or she wants to make a change and is willing to take
steps toward a permanent change.
If the client is willing to try to quit smoking, the provider then moves on to
the assist portion of the 5 A’s. It is at this point that the provider helps the
client to come up with reasonable goals toward quitting smoking, such as
using medication to reduce nicotine cravings or to attend support groups for
further encouragement. The provider can give the client resources to further
support what has been discussed during the motivational interview.
Finally, the arrange portion of the 5 A’s involves arranging follow-up
appointments to see if the client is continuing to take the steps that were
discussed. This might mean following up with a phone call to check in with
the client and determine how things are going, a follow-up appointment to
meet together again to talk more, or an appointment with another
professional who can continue to help the client in his or her work toward
the goal, such as a meeting with a medical specialist.
Whether or not patients with heart disease are willing to make these
changes in their lifestyle is governed by a number of factors, including
socioeconomic status, family or social support, and cultural factors. During
the discussion of the need to make changes to manage heart disease, the
provider must assess what factors are prohibiting the client from making
changes and then work with the client to address those issues.
For patients who have significant issues to overcome before starting to
change or for those who state that they have too many obstacles standing in
the way before they can get started might mean altering the goals
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somewhat to fit what these patients can do. In some cases, it is better to
make some progress toward a lesser goal than to set a higher goal and then
fail when it is too difficult for the patient. For example, a patient who never
exercises and who leads a very sedentary life, including a desk job where he
sits for most of the day, followed by spending his evenings on the couch at
home watching television, is most likely not a candidate for setting a goal of
becoming actively involved in a running program and striving to run a 10K
by the end of the month. The patient may strive for this goal but might be
more likely to fail or give up because it is too much of a change to start out.
Although the patient may incorporate lifestyle changes and eventually reach
the point where he or she is an active runner, it may be best to start out
with smaller goals that can be achieved to improve self-efficacy. The patient
could instead begin with a walking program where he or she walks twice
around the block, two times a week. Although this goal would not meet the
exercise recommendations given by the American Heart Association for
moderate intensity exercise on five out of seven days a week, the patient is
still doing more exercise than before. If the patient achieves this goal and is
able to implement regular walking, then they may increase the time spent
walking, as well as the number of days each week. The patient may walk
further each time than previously done, and increase from two days a week
to four. Some patients need to slowly work toward their goals to improve
confidence and desire for change.
The American Heart Association has recommended motivational interviewing
as an effective method of promoting healthy outcomes by making lifestyle
changes in patients with heart disease [44]. Use of MI can bring about
changes in some patients that continue long term. A study by Hardcastle, et
al., in the International Journal of Behavioral Nutrition and Physical Activity
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compared patients who received five sessions of motivational interviewing,
combined with exercise and nutrition information with a group who only
received the information but no MI. The patients were measured for their
physical activity, dietary intake, BMI, blood pressure, and cholesterol
immediately following the completion of the study and then again a year
later.
The goal of the study was to show that the use of MI not only produces
changes in lifestyle factors for patients, but also to determine whether the
changes can be maintained long term. The study showed significant changes
in the patients who used motivational interviewing as part of their
interventions in the areas of weight loss and cholesterol management. The
MI intervention was particularly effective among those patients with the
highest risk factors for heart disease. The study found significant increases
in the amount of walking added among patients who used MI and as a
lifestyle change, 12 months after the interventions ended. Alternatively, the
group who did not use MI during the study had increased levels of
cholesterol and BMI in the 12 months following the interventions [44].
Another study found in the Journal of Clinical Nursing performed a
systematic review of literature to analyze current research findings that used
motivational interviewing as part of practice in helping clients change to
improve their cardiovascular health. The review included four metaanalyses, a systematic review, three literature reviews, and five primary
studies related to motivational interviewing and its use in promoting
cardiovascular health. The review found strong evidence that motivational
interviewing is useful and effective when focusing on and implementing
changes to promote cardiovascular health and, thereby, reducing the risk of
disease [45].
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Clearly, motivational interviewing has benefits in helping clients to make
changes that will improve their lives and that will reduce the risk or impact
of heart disease. Because so many patients with heart disease have multiple
factors that must be addressed, including weight management issues,
decreased activity levels; laboratory outcomes that can indicate severe risk
of cardiac problems, including elevated total cholesterol levels, elevated
levels of inflammation in the body that can lead to blood vessel changes, and
increased levels of triglycerides; as well as other common contributing
factors, such as smoking or high blood pressure, motivational interviewing
can work in each of these situations to come up with goals to make changes
as needed in the lives of many people. Whether the change is radical and
permanent, or whether the patient is able to achieve even smaller goals, MI
can be used successfully to help people live longer by reducing their risks of
heart disease.
MENTAL HEALTH AND MI
Severe and persistent mental illness, formerly referred to as chronic mental
illness, consists of a group of conditions that cause complex symptoms and
behaviors and that require ongoing treatment and management. People who
have persistent mental illness often have symptoms that worsen and then
abate over time, but do not necessarily go away permanently. Depending on
the severity of the diagnosis, patients with severe and persistent mental
illness may require assistance with activities of daily living, obtaining jobs,
finding housing, going to school, or making social contacts [45].
Because severe and persistent mental illness is a long-term condition that
often results in periods of relapse and recovery, healthcare providers must
be aware of possible complications that can develop as part of maintaining
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appropriate behavior and for living as productive and healthy of life as
possible. Ongoing case management and interventions may be necessary in
some situations, while in other situations, daily thoughts and behaviors are
under control but crisis situations may develop on an occasional basis. Some
examples of common severe and persistent mental illnesses include severe
depression, bipolar disorder, schizophrenia and delusional disorder [45].
Persistent mental illness can cause difficulties with thoughts and behaviors
for those who have been diagnosed. The affected person may have difficulty
controlling his or her thoughts, which can lead to behavior that is sometimes
considered erratic, bizarre, confusing, or concerning. For many people who
struggle with mental illness, the disease takes over a considerable portion of
their lives, impacting their abilities to function on a daily basis, and putting
them at higher risk of complications that can develop as a coping
mechanism for the ongoing illness, such as substance abuse, violence, or
suicidal ideation.
According to the American Foundation for Suicide Prevention, 90 percent of
people who die by suicide had some form of mental disorder at the time of
their deaths [47]. Suicide, which may also be classified as self-directed
violence, is the willful taking of one’s own life. People who commit suicide do
so for a variety of reasons, although as many as one-third do
did not communicate their suicidal intent prior to death [47].
Even more concerning are the results of one study that showed
approximately 45 percent of people studied who had died by suicide had
seen a primary care provider within the past month before their deaths and
77 percent had seen a primary care provider within the past year [47].
These statistics place the role of primary care providers and other healthcare
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providers in an important position to recognize situations that could
contribute to suicidal ideation and intervene as necessary.
The interventions provided through motivational interviewing can be helpful
for patients who are considering suicide. If a provider has recognized the
possibility of suicidal ideation in a patient, whether due to the presence of
mental illness or through exhibiting other concerning symptoms, the nonjudgmental and non-threatening approach used with motivational
interviewing could be a helpful intervention for the patient.
A 2012 preliminary trial published in The Journal of Clinical Psychology
worked with veterans who were hospitalized for psychiatric suicidal ideation
to determine if motivational interviewing was effective as part of treatment.
The participants completed two sessions of motivational interviewing after a
preliminary assessment, another session following treatment and
hospitalization and a final session 60 days after the intervention. The study
showed that the participants were open to motivational interviewing as part
of therapy and responded well to it as an intervention. The participants
showed significant reductions in suicidal ideation, both after treatment had
ended and at the 60-day follow-up appraisal. This study, because it is
preliminary, opens the doors for further research into use of motivational
interviewing as part of treatment and change for people who are
experiencing thoughts of suicide and who need intervention [46].
Depression is another type of mental illness that can be classified according
to different terms, depending on the types of symptoms experienced, the
extent of the symptoms, and the length of time they have occurred.
Depression is one of the most common mental health disorders in the United
States. It is characterized by persistent feelings of sadness, emptiness,
hopelessness, or pessimism; a loss of interest in normal activities that used
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to be pleasurable, suicidal ideation, fatigue, sleep problems, changes in
appetite, difficulties with memory and concentration; and some physical
discomfort, such as joint pain, or chronic back pain [48].
Depending on patient circumstances and symptoms, the main categories of
depression are major depression and persistent depressive disorder. Major
depression occurs when symptoms considerably disrupt a person’s life and
ability to function on a daily basis, while persistent depressive disorder may
occur as underlying feelings of depression and its symptoms occur
continuously over the course of at least two years. A person with persistent
depressive disorder may have occasional exacerbation of depression
symptoms, causing a disruption of daily activities, as well as the ongoing
symptoms [48].
Other types of depression can also cause significant problems for some
people but are classified slightly differently than major depression or
persistent depressive disorder. Postpartum depression is diagnosed when
depressive symptoms occur after delivering a baby; seasonal affective
disorder results in depressive symptoms that more commonly develop
during certain times of the year, such as during the winter when there is less
environmental light; and psychotic depression, which occurs when a person
has symptoms of depression as well as another type of mental illness, such
as delusional disorder.
Bipolar disorder is also classified as a form of depression, as the person
suffering from this condition has periods of depression followed by periods of
mania. When depression is apparent, the patient with bipolar disorder
experiences the symptoms associated with depression, including sadness,
fatigue, and hopelessness. The person may later shift to a time of mania in
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which he or she experiences a very high mood and has increased energy and
tolerance for activities. The cycles back and forth between depression and
mania characterize bipolar disorder. The illness used to be called manicdepression [48].
People who suffer from depression are at higher risk of complications
because the symptoms are often overwhelming. They may be more likely to
consider suicide or other types of self-harm. People with depression may
also suffer from other health conditions that either contributes to the
depression or that have developed as a result of the depressive symptoms
[48]. For example, a person who suffers from chronic pain from arthritis
may develop symptoms of depression when he is unable to function in the
same way that he once did.
Treatment of depression through motivational interviewing can be
challenging because it can be difficult to actively engage patients who are
suffering from depressive symptoms to engage in a manner that leads to
change. Treatment of depression through pharmacologic intervention may
occur concurrently with motivational interviewing. In some situations,
motivational interviewing may play a role in getting a client to take his or
her medications to treat the depression. In other cases, MI can be adjunctive
to medication use.
Motivational interviewing can also be used in conjunction with other
traditional forms of treatment for depression that are related to counseling
or psychotherapy. One form of psychotherapy that is commonly used as part
of treatment for depression is cognitive-behavioral therapy (CBT). CBT
focuses on negative thoughts, views, and opinions that the client holds and
examines how those ideas affect his or her behavior. It may be used as a
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type of therapy for a number of mental disorders and has been effectively
used as treatment for depression [49].
Burke, in Cognitive and Behavioral Practice, looked at how well motivational
interviewing could be blended throughout the use of CBT to assess
motivation, encourage self-efficacy, and resolve ambivalence among patients
suffering from depression. Because motivational interviewing is not
necessarily a distinct therapy itself, it can be blended with other therapeutic
treatment approaches as a means of connecting
with patients on a deeper level.
Cognitive behavioral therapy and motivational interviewing have a number
of elements in common. Both types of interventions work collaboratively
with clients to set goals and both involve checking in or following up with
clients to evaluate how they are progressing toward their goals [49].
Although cognitive behavioral therapy has been beneficial in treating many
patients with depression, studies have shown that many patients who have
undergone CBT for depression have successful remission rates of depressive
symptoms at approximately 50 percent of those who undergo pharmacologic
treatment for depression. Despite large numbers of patients undergoing CBT
for depression, there are still many of these patients who continue to suffer
from depressive symptoms, even after this therapy [49]. Alternatively, there
have been studies that have shown that patients with depression who went
through therapy, focused on motivation and behavior activation, responded
better to the treatment than those who went through therapy that was
focused on cognitive interventions and used pharmacologic treatment.
Because motivational interviewing focuses on behavior activation and
motivation as studied, it is a viable intervention to add as part of traditional
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therapy and may show more promising results with depressed patients than
when it is not used [49].
Patients with mental illness are at higher risk of developing concurrent
disorders, most commonly substance abuse. This is often referred to as dual
diagnosis or co-morbidity and occurs when one or more illnesses occur in a
person, whether at the same time or one after the other. For instance,
people who struggle with drug addiction are almost twice as likely to suffer
from anxiety or mood disorders when compared to the general population
[50].
Rates of mental illness are surging among adolescent clients, which are also
often concurrent with substance abuse issues. A study by The Center for
Substance Abuse Treatment found that 62 percent of male clients and 83
percent of female clients entering treatment facilities for substance abuse
also had concurrent mental health diagnoses [13].
The co-morbidity of mental illness combined with substance abuse puts MI
practitioners in the position of addressing more than one problem behavior.
When discussing options with the client and assessing levels of motivation,
providers and clients may need to determine the highest area of priority for
change or whether to tackle both issues at the same time. The change talk
that occurs as part of motivational therapy encourages individuals to share
more of their thoughts and feelings about their behavior in a method that is
open-ended, non-judgmental, and promotes self-efficacy. When the client
opens up and expands on certain subjects because of the change talk that
happens during MI, he or she may be more likely to see the discrepancies
between their current behavior and the lifestyle or behavior that they would
like to have, which also may promote change.
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Another important aspect of motivational interviewing that is essential to
remember when working with clients who have co-morbidities of mental
health issues is that eliciting change in the client who is not ready for change
is counterproductive, a waste of time, and can even be damaging to the
therapeutic relationship. Thus, the provider needs to approach each
individual with his or her diagnoses as individuals and at the levels of
motivation in which they present. [51] Additionally, clients who are
cognitively impaired at times because of their mental illnesses may also
benefit from the elicit-provide-elicit technique of motivational therapy. This
technique asks the client permission before offering or generating
information or advice. When the client approves, the provider then gives the
information and asks the client to respond. Using this process in a client who
may be cognitively impaired because of mental illness can help to better
keep the client on track with the conversation and what decisions are being
made. The client often must repeat back the important information to the
provider as part of this method, which further conveys his or her
understanding of the topic and keeps the client on track [51].
According to the book, Intervention in Mental Health-Substance Abuse, this
method is similar to the PAPA technique. The PAPA method starts with:

Permission: the client seeking permission to give advice or information
and when allowed;

Asks: the provider then asks the client what he or she knows about
the topic they are discussing;

Provided: further information is provided to the client to clarify about
the topic or to summarize his or her understanding of the topic;

Asked: finally, the client is asked about what he or she thinks of the
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topic and the idea of change.
The PAPA method may elicit more information from the client and help him
or her to stay on track with the conversation [51].
Personality disorders are a prevalent form of persistent mental illness and
are classified into three groups, according to the American Academy of
Family Physicians [52]:

Cluster A: schizoid and paranoid personality disorders

Cluster B: borderline, histrionic, narcissistic, and antisocial
personality disorders

Cluster C: avoidant, dependent, and obsessive-compulsive
personality disorders
Cluster A personality disorders are classified according to bizarre or odd
characteristics among patients, and may involve an inability to maintain
close relationships as well as misguided thoughts and feelings related to
others. For example, some people who suffer from cluster A personality
disorder may have a lot of paranoid feelings from others and feel judged or
threatened.
Cluster B personality disorders are more related to dramatic, self-involved
behavior. They may include feelings of grandiosity, attention seeking, or lack
of impulse control. People with cluster B types of illnesses can also cause
difficulties with relationships when excessively emotional behavior or the
near-constant need for validation gets in the way of the normal give and
take of relationships.
Cluster C illness is marked by anxious or fearful behaviors, which often
impact relationships with others. Cluster C disorders may cause social
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phobia, overdependence on others, perfectionism and control, or clingy
behaviors, which are often challenging to healthcare providers as well as the
families and friends of these patients [52].
An important aspect of working with patients who have personality disorders
is to avoid succumbing to or otherwise being drawn into their situations. A
provider who is working with a patient who has a personality disorder must
maintain a line of professionalism and a working relationship to avoid
becoming too involved in the situation. For example, a provider working with
a patient who has histrionic personality disorder may need to have a number
of discussions that involve the patient’s emotions and feelings. The patient
may consistently talk about a number of situations that have caused her
pain or that have been difficult for her, in an effort to get the provider to feel
sorry for her and comfort her. In order to provide effective care for the
patient, the provider must be aware of the challenges presented with this
situation before even starting the therapeutic relationship, or she could
easily get too involved. It can be difficult to know how to provide comfort
and help to a patient without being drawn too far into the personal lives of
some patients with personality disorders [52].
Personality disorders are treated in psychiatric practice through counseling
and intervention but many patients with these types of mental illness are
also seen for primary care in a number of other community settings,
including by general health practitioners. As noted by their title, personality
disorders cause changes in personality, which may be characterized in a
number of methods, from bizarre or confusing words and attitudes to
outright anger, aggression, and violence. Often, providers who work with
people with personality disorders are challenged with providing quality care
while simultaneously managing feelings of frustration, helplessness, or even
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anger when trying to help these patients because of their personalities and
attitudes [52].
Personality disorders may be prevalent in almost 15 percent of the
population in the United States. It is not uncommon for some people to have
more than one type of personality disorder or concurrent mental illness,
including substance abuse that is connected with the condition [52].
Motivational interviewing has been shown to be helpful when working with
some patients who have personality disorders. While the MI techniques will
not change the disorder, it can help patients suffering from these illnesses to
make positive choices that impact themselves and their behavior as well as
their relationships with others. Motivational interviewing can be used as part
of other therapeutic interventions or even during primary care evaluations to
help clients with personality disorders with decision-making and through
setting goals that will create positive outcomes.
In the example of the patient with histrionic personality disorder, the
provider may use motivational interviewing techniques during an
appointment to discuss the clients’ need for taking care of their children. The
client may recognize that he or she has trouble taking care of their children
and getting home in time to help their spouse by being involved in the
family. Through MI techniques, the provider could work with the client to
come up with goals that will support this desire for change in one area of
their life. The client might set a goal to start picking their children up from
daycare at the same time each day, or spending 30 minutes every evening
playing games with them in a focused manner. The focus of motivational
interviewing in this situation does not cure the personality disorder or even
reduce demonstration of symptoms to a large degree, but rather helps the
client with the disorder to better manage his or her life around the condition.
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One condition that providers may need to manage and that may coincide
with personality disorders is crisis intervention. A crisis occurs when a
person is overwhelmed by events and is unable to cope with the situation. If
the person cannot handle what is happening, he or she may develop
maladaptive behaviors in a further attempt to cope, such as through
substance use or violence, or the person may succumb to the situation and
exhibit behaviors that demonstrate an unwillingness or inability to function,
such as having panic attacks or psychotic events [54].
Crisis intervention aims to work with clients in acute distress to help them
manage the current situation. It may then go on to help affected clients with
problem solving or assist them with changing their situations so that they
are less likely to have another crisis. Therapy for crises involves counseling
and working with family members and friends of the affected person to
provide support and to educate those involved about appropriate coping
mechanisms that are available [54]. It is important, however, that some
techniques be used for a short time instead of a long therapeutic
relationship. In many situations of working with people who are in crisis or
who have personality disorders, motivational interviewing may need to be
delivered in short but intense sessions in order to prevent the client from
becoming dependent on the therapist [54].
Studies have shown that motivational interviewing can be helpful when
working with clients as part of crisis intervention. Motivational interviewing
may be used concurrently with other forms of behavioral therapy and crisis
intervention methods. It shows the client that the provider is a trusted
partner in therapy and intervention and is someone who is willing to help
bring about change. It also helps the client to better visualize the
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discrepancies in his or her behavior and the ultimate goals or outcomes [53].
For example, if a client is seeking help for excessive drinking and has
concurrent narcissistic personality disorder, he may meet with a therapist for
crisis intervention for help with stopping the harmful behaviors. During the
course of the intervention, the practitioner may utilize motivational
interviewing to discuss the client’s current situation and assess his or her
goals and objectives.
During the interview, the client may become more aware that their current
situation: drinking to excess and taking advantage of their personal
relationships, is far from where they want to be. The provider can then use
techniques of MI to promote self-efficacy in the client. The techniques leave
the decision ultimately up to the client, although the provider will act as a
guide along the way.
Some personality disorders also leave patients more prone to violence and
aggressive behavior, which could lead to a need for crisis intervention.
Motivational interviewing is also beneficial in these situations because the
core of the MI sessions is to have the client take responsibility for his or her
own behavior. If the client is willing to change or sees the need for it, the
provider works with the client to help him or her make the changes but
ultimately it is the client’s responsibility to take charge of angry or
aggressive behavior.
Anger is a normal feeling that may occur in response to feeling judged,
slighted, insulted, or ignored. It can develop based on real or perceived
situations. It is important that clients understand that anger is a normal
emotion that almost everyone feels at one time or another, however,
aggression and violence as a result of anger are not normal.
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Peter Prisgrove of the Western Australian Department of Corrective Services
states that providers can work with clients on anger control issues through
such interventions as cognitive-behavioral skills training, in which the focus
is on recognizing the impact of thoughts related to behavior and working
through negative or angry thoughts to recognize them and deal with them
before they lead to problem behaviors. Behavioral skills training also
consider those situations that might lead to aggressive or negative reactions
and teaches the client how to behave and handle him- or herself when the
urge to lose control happens [55].
When using motivational interviewing as part of cognitive or behavioral skills
training, the client may have mixed responses for being motivated to
change, depending on his or her background and the situation at hand.
Some clients feel true remorse and are motivated to change because they
have hurt someone they care for or they are facing legal consequences of
their actions. Alternatively, other clients may have little motivation to
change and may feel justified in their actions or continue to feel angry about
the situation. Just as with any other situation that requires motivational
interviewing, the provider must first assess the level of motivation from the
client and his or her amount of ambivalence toward change before
progressing into change talk.
Prisgrove also states that there are two main types of aggression often seen
among individuals who are in treatment for this kind of behavior:
instrumental aggression and reactive aggression. Instrumental aggression
often occurs because of a cause that the offender deemed necessary or
justified at the time, or to achieve some sort of objective. An example might
be when a client attacks their employer because they have been angry about
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unfair treatment at work and believes that through force the employer can
be made to change. Alternatively, reactive aggression is the result of loss of
control over a situation in which the client acts out. An example might be
when a client comes home and becomes angry and violent toward their
spouse because he or she forgot to run an errand for them [55].
In the treatment sense, different clients obviously will arrive for help and
treatment of different needs. The provider using motivational interviewing
will need to understand the background of the aggression, or whether it was
instrumental or reactive aggression, in order to better understand the
client’s level of motivation for change. Finally, when working with aggressive
clients, whether or not due to underlying personality disorders, the
probability for repeat offenses is high [55].
A client may be seen for therapy or treatment of an aggressive outburst, go
through the steps of change, and then return for treatment again at a later
date. The change invoked through motivational interviewing may or may not
be permanent because the anger and aggression takes on an almost
addictive framework in which the client is drawn to repeating the same
offenses over and over. A client in this situation may need repeated sessions
or ongoing, long-term treatment and therapy in order to handle aggressive
feelings and avoid acting out. Studies have shown that the most difficult
area of treating clients with anger-control issues is the long-term
maintenance of behavior change [55].
The goal, therefore, of treatment along with motivational therapy is not to
cure the client of their anger, but rather to help them change behavior so
that he or she makes better choices when frustrating situations arise. This
involves learning new skills, and the motivational interviewing process is
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there to help the client acquire these skills to implement them into daily life.
If a lapse in behavior occurs, the client may have learned the skills needed
to cope with the situation before he or she completely loses control. The
provider, however, can use this lapse in behavior in a positive way to
reinforce the need for change and to elicit further growth in the client [55].
Motivational interviewing has also been used successfully as an adjunct to
other methods of working with clients to promote change. There are a
number of different resources in the community that are available to help
people see the need for change and to implement certain interventions into
their way of life, whether through therapy, hypnosis, meditation, or other
methods. In some practices, motivational interviewing is incorporated into
techniques to improve outcomes for patients already seeking care through
other alternative measures.
Mindfulness is a concept that involves choosing to live in the present
moment and accepting it, whatever is happening. Mindfulness originally
started as a Buddhist practice but it is being incorporated into many different
medical and psychological therapies today after researchers have discovered
some of its many health benefits. Mindfulness has been shown to have a
positive impact on mental health, including depression, substance
abuse, anxiety, and obsessive-compulsive disorder. It can also benefit
physical health and has been shown to lower blood pressure, relieve stress,
and reduce chronic pain [35].
Mindfulness involves a form of meditation in which the person practicing it
uses techniques to focus on what is happening within him- or herself in the
present moment. It may involve focusing on body sensations, emotions, or
sensory input that is happening, recognizing them for what they are, and
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accepting them without judgment [35]. People who use mindfulness
regularly can learn the techniques and use them on their own or they may
continuously practice them within groups or with others.
Mindfulness may also be incorporated into motivational interviewing and
pairing these two methods together has shown promise for healing in some
areas. The Center for Mindfulness in Corrections uses mindfulness to
promote research, evidence-based practices, improved environments, and
staff wellbeing in the field of corrections. The center has used mindfulness
techniques among police officers and prison guards to help them manage
the stress of their jobs and to better handle the strain and difficulties
sometimes associated with working in corrections. The mindfulness
techniques have helped workers to relieve some of the stress of their daily
jobs and to cultivate a more positive response to certain situations instead of
acting out in anger or reacting in a stressful manner [36].
The Center for Mindfulness in Corrections also uses motivational interviewing
as part of the mindfulness techniques when working with officers and
corrections agents. By pairing motivational interviewing with mindful
behavior and utilizing mindful meditation when considering choices, the
center has seen changes in their clients. In general, the clients have been
able to more readily address concerns in their lives, focus on future-oriented
situations that may require change so that they can readily accept them
rather than react poorly when they occur, and feel affirmed at the
completion of positive goals. Motivational interviewing is a routine part of
some of the techniques used at the Mindfulness Center because the
organization recognizes the benefits of connecting the two methods [36].
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SUMMARY
Motivational interviewing can be effective in a number of situations in which
clients require help for making changes in their lives. The concepts of
motivational interviewing can be incorporated into routine physical exams or
through specialist interventions, and they may be used as part of
conversations or therapy sessions within the acute healthcare setting or in
primary health or community care. Regardless of the exact situation in which
motivational interviewing is used, its techniques and practices can bring
hope and help to many people by teaching them how to make decisions and
providing a coaching method to guide them toward change.
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References:
1. Houghton, J. (2010, Apr.). Joan Freeman, CEO Pieta House. Retrieved
from https://www.flickr.com/photos/joehoughton/4518268998/
2. Wikipedia Commons. (2013, Jun.). Medical nutrition therapy. Retrieved
from http://commons.wikimedia.org/wiki/File:MANNA_Counseling.jpg
3. Smith, H. (2007, Jul.). Helen Smith, psychologist. Retrieved from
http://commons.wikimedia.org/wiki/File:Helen_Smith_psychologist.jpg
4. Pixabay. (2010, Feb.). Counseling, stress, angry. Retrieved from
http://pixabay.com/en/counseling-stress-angry-99740/
5. Dart, M. (2011). Motivational interviewing in nursing practice:
Empowering the patient. Sudbury, MA: Jones and Bartlett Publishers
6. Community Care of North Carolina. (2013). CCNC Motivational
interviewing resource guide. Retrieved from
https://www.communitycarenc.org/populationmanagement/behavioral-health-page/motivational-interviewing/
7. O’Brien, P., Kennedy, W. Z., Ballard, K. A. (2012). Psychiatric mental
health nursing: An introduction to theory and practice (2nd ed.).
Burlington, MA: Jones & Bartlett Learning
8. Wagner, C., Conners, W. (2003, Jan.). Interaction techniques.
Retrieved from
http://motivationalinterview.net/clinical/interaction.html
9. Kamya, H. (2012). Motivational interviewing and field instruction: The
FRAMES model. The Field Educator (2.1). Retrieved from
http://fieldeducator.simmons.edu/article/motivational-interviewingand-field-instruction-the-frames-model/
10.
American Society on Aging, American Society of Consultant
Pharmacists Foundation. (2006). Facilitating behavior change.
Retrieved from
http://www.adultmeducation.com/FacilitatingBehaviorChange_2.html
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
99
11.
Siegle, D. (2000). An introduction to self-efficacy. Retrieved
from http://www.gifted.uconn.edu/siegle/selfefficacy/section1.html
12.
Naar-King, S., Suarez, M. (2011). Motivational interviewing with
adolescents and young adults. New York, NY: The Guildord Press
13.
Slack, K. (2010). Motivational interviewing: A potential
framework for co-occurring disorders treatment for adolescents.
Sacramento, CA: On Track Resources
14.
The RAND Corporation. (2014). Group MI for teens. Retrieved
from http://groupmiforteens.org/
15.
McNamara, E. (Ed.). Motivational interviewing: Theory, practice
and applications with children and young people. Merseyside, UK:
Positive Behaviour Management (PBM)
16.
Erickson, S. J., Gerstle, M., Feldstein, S, W. (2005, Dec.). Brief
interventions and motivational interviewing with children, adolescents,
and their parents in pediatric health care settings. Archives of
Pediatrics & Adolescent Medicine 159(12), 1173-1180. Retrieved from
http://archpedi.jamanetwork.com/article.aspx?articleid=486200
17.
Crowther, T. R. (2008). Motivational interviewing and the older
population in psychiatry. Psychiatric Bulletin 32: 23-25. Retrieved from
http://pb.rcpsych.org/content/32/1/23
18.
Chi-Ying Chung, R., Bemak, F. (2002). The relationship of
culture and empathy in cross-cultural counseling. Journal of
Counseling and Development 80, 154-159.
19.
Burke, N. J., Bird, J. A., Pasick, R. J. (2009, Oct.). Social and
cultural meanings of self-efficacy. Health Education & Behavior 36(5
Suppl), 111S-128S. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921833/
20.
Pregnancy Care Management Services. (2012, Dec.). Pregnancy
care management patient engagement scripting using motivational
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
100
interviewing. [Program Manual]. Retrieved from
http://whb.ncpublichealth.com/provPart/
21.
ACOG Committee Opinion No.423. (2009, Jan.). Motivational
interviewing: A tool for behavior change. Obstetrics & Gynecology 113:
243-246. Retrieved from
http://www.acog.org/Resources_And_Publications/Committee_Opinion
s/Committee_on_Health_Care_for_Underserved_Women/Motivational_
Interviewing_A_Tool_for_Behavior_Change
22.
University of Minnesota. (2014). Stages of readiness for change.
Retrieved from
http://www.takingcharge.csh.umn.edu/activities/stages-readinesschange
23.
American College of Obstetricians and Gynecologists (ACOG).
(n.d.). Drinking and reproductive health: A fetal alcohol spectrum
disorders prevention tool kit. Retrieved from
http://www.acog.org/About_ACOG/ACOG_Departments/Tobacco__Alc
ohol__and_Substance_Abuse/Drinking_and_Reproductive_Health_Tool
_Kit_for_Clinicians
24.
Lai, D. T. C., Cahill, K., Qin, Y., Tang, J. L. (2010). Motivational
interviewing for smoking cessation (Review). Cochrane Database of
Systematic Reviews. doi: 10.1002/14651858.CD006936.pub2
25.
American Cancer Society. (2014, Feb.). Why is it so hard to quit
smoking? Retrieved from
http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittings
moking/guide-to-quitting-smoking-why-so-hard-to-quit
26.
Martino, S., Ondersma, S., Howell, H., Yonkers, K. (n.d.). A
nurse-delivered brief motivational intervention for women who screen
positive for tobacco, alcohol, or drug use [Intervention Manual].
Retrieved from
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
101
http://www.mirecc.va.gov/visn1/docs/products/Project_START_MIN_Manual.pdf
27.
Carino, J. L., Coke, L., Gulanick, M. (2007). Using motivational
interviewing to reduce diabetes risk. Retrieved from
http://www.medscape.com/viewarticle/496829
28.
International Diabetes Federation. (2014). About diabetes.
Retrieved from http://www.idf.org/about-diabetes
29.
Case Western Reserve University. (2011). Motivational
interviewing. Retrieved from
http://www.centerforebp.case.edu/practices/mi
30.
Motivational Interviewing Network of Trainers (MINT). (2013).
What is motivational interviewing? Retrieved from
http://www.motivationalinterviewing.org/
31.
Dellasega, C., Añel-Tiangco, R. M., Gabbay, R. A. (2012, Jan).
How patients with type 2 diabetes mellitus respond to motivational
interviewing. Diabetes Research and Clinical Practice 95(1), 37-41.
Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686502/
32.
Dellasega, C., Gabbay, R., Durdock, K., Martinez-King, N.
(2010). Motivational interviewing to change type 2 diabetes self-care
behaviours. Journal of Diabetes Nursing 14(3), 112-118.
33.
Lundahl, B., Burke, B. L. (2009). The effectiveness and
applicability of motivational interviewing: A practice-friendly review of
four meta-analyses. Journal of Clinical Psychology 65(11), 1232-1245.
34.
Lemmon, M. (2006, Aug.). Talking with Matt. Retrieved from
https://www.flickr.com/photos/mplemmon/215790292/in/photostream
/
35.
Harvard Medical School. (n.d.). Benefits of mindfulness.
Retrieved from http://www.helpguide.org/harvard/mindfulness.htm
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
102
36.
Center for Mindfulness in Corrections. (n.d.). Motivational
interviewing. Retrieved from http://mindfulcorrections.org/
37.
National Alliance on Mental Illness (NAMI). (2012, Jul.).
Cognitive behavioral therapy (CBT). Retrieved from
http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About
_Mental_Illness/About_Treatments_and_Supports/Cognitive_Behavior
al_Therapy1.htm
38.
Barrowclough, C., et al. (2010). Integrated motivational
interviewing and cognitive behavioural therapy for people with
psychosis and comorbid substance misuse: a randomised controlled
trial. BMJ 341. doi: 10.1136/bmj.c632
39.
Emmons, K. M., Rollnick, S. (2001). Motivational interviewing in
health care settings: Opportunities and limitations. American Journal
of Preventive Medicine 20(1), 68-74.
40.
Franklin, B. A., Brinks, J., Friedman, H. (2013). Foundational
factors for cardiovascular disease: Behavior change as a first-line
preventive strategy. Circulation 128, 2169-2176. doi:
10.1161/01.cir.0000435173.25936.e1.
41.
WebMD. (2014). Heart disease: Symptoms and types. Retrieved
from http://www.webmd.com/heart-disease/guide/heart-diseasesymptoms-types
42.
National Heart, Lung, and Blood Institute. (2011, Dec.). How
does smoking affect the heart and blood vessels? Retrieved from
http://www.nhlbi.nih.gov/health/health-topics/topics/smo/
43.
Agency for Healthcare Research and Quality. (2012, Dec.). Five
major steps to intervention (The “5 A’s”). Retrieved from
http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/5steps.html
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
103
44.
Hardcastle, S. J., Taylor, A. H., Bailey, M. P., Harley, R. A.,
Hagger, M. S. (2013). Effectiveness of a motivational interviewing
intervention on weight loss, physical activity and cardiovascular
disease risk factors: A randomised controlled trial with a 12-month
post-intervention follow-up. International Journal of Behavioral
Nutrition and Physical Activity 10(40).
45.
Thompson, D. R., Chair, S. Y., Chan, S. W., Astin, F., Davidson,
P. M., Ski, C. F. (2011). Motivational interviewing: A useful approach
to improving cardiovascular health? Journal of Clinical Nursing 20,
1236-1244. doi: 10.1111/j.1365-2702.2010.03558.x
46.
Britton, P.C., Conner, K.R., Maisto, S. A. (2012, Sep.). An open
trial of motivational interviewing to address suicidal ideation with
hospitalized veterans. Journal of Clinical Psychology 68(9), 961-971.
doi: 10.1002/jclp.21885
47.
American Foundation for Suicide Prevention. (2014). Key
research findings. Retrieved from http://www.afsp.org/understandingsuicide/key-research-findings
48.
National Institute of Mental Health. (2011). What is depression?
Retrieved from
http://www.nimh.nih.gov/health/publications/depression/index.shtml
49.
Flynn, H. A. (2011). Setting the stage for the integration of
motivational interviewing with cognitive behavioral therapy in the
treatment of depression. Cognitive and Behavioral Practice 18, 46-54.
50.
National Institute on Drug Abuse. (2011, Mar.). Comorbidity:
Addiction and other mental disorders. Retrieved from
http://www.drugabuse.gov/publications/research-reports/comorbidityaddiction-other-mental-illnesses
51.
Cooper, D. B., (Ed.). Intervention in mental health-substance
abuse. London, UK: Radcliffe Publishing Ltd.
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
104
52.
Angstman, K. B., Rasmussen, N. H. (2011, Dec.). Personality
disorders: Review and clinical application in daily practice. American
Family Physician 84(11), 1253-1260. Retrieved from
http://www.aafp.org/afp/2011/1201/p1253.html
53.
James, R. K., Gilliland, B. E. (2013). Crisis intervention
strategies (7th ed.). Belmont, CA: Cengage Learning
54.
Tidy, C. (2012, Oct.). Crisis intervention. Retrieved from
http://www.patient.co.uk/doctor/crisis-intervention
55.
Prisgrove, P. (n.d.). A relapse prevention approach to reducing
aggressive behaviour. Retrieved from
http://aic.gov.au/media_library/publications/proceedings/19/prisgrove
.pdf
56.
Caron Treatment Centers. (2013). Substance abuse vs.
addiction. Retrieved from http://www.caron.org/substance-abuse-vsaddiction
57.
Grant, J. E., Potenza, M. N., Gorelick, D. A. (2010, Sep.).
Introduction to behavioral addictions. The American Journal of Drug
and Alcohol Abuse 36(5), 233-241. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164585/
58.
Elements Behavioral Health. (2013). Motivational interviewing
for addiction treatment. Retrieved from
http://www.elementsbehavioralhealth.com/addiction/addictiontreatment/
59.
National Institute on Alcohol Abuse and Alcoholism. (2005,
Feb.). FASD kid. Retrieved from
http://commons.wikimedia.org/wiki/File%3AFASkid.gif
60.
Medical News Today. (2013, Jul.). What to eat during pregnancy.
Retrieved from
http://www.medicalnewstoday.com/articles/246404.php
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
105
61.
Cionnaith, F. (2013, Jan.). Pregnant women will not get vaccine
from GPs. Retrieved from
http://www.irishexaminer.com/ireland/health/pregnant-women-willnot-get-vaccine-from-gps-219398.html
62.
Perry, B. (2009, Nov.). American Cancer Society’s Great
American Smoke Out. Retrieved from
http://commons.wikimedia.org/wiki/File:No_Smoking__American_Cancer_Society's_Great_American_Smoke_Out.JPG
63.
Wikipedia Commons. (2012, Aug.). Risks from smoking.
Retrieved from
http://so.wikipedia.org/wiki/Template:Sawirka_Maanta_1_Juun
64.
Wikipedia Commons. (2007, Mar.). Nicotine patch. Retrieved
from
http://en.wikipedia.org/wiki/Nicotine_patch#mediaviewer/File:Nicoder
m.JPG
65.
Wikipedia Commons. (2008, Nov.). Alcohol desgracia. Retrieved
from http://commons.wikimedia.org/wiki/File:Alcohol_desgracia.jpg
66.
Pixabay. (2012, Dec.). Addiction, antibiotic, capsule. Retrieved
from http://pixabay.com/en/addiction-antibiotic-capsule-care-71538/
67.
U. S. Army Corps of Engineers. (2012, Jan.). USACE promotes
healthy living in Europe with employee-run support group. Retrieved
from https://www.flickr.com/photos/34728058@N08/6683158541/
68.
National Heart, Lung, and Blood Institute. (2013, Mar.).
Coronary heart disease: Atherosclerosis. Retrieved from
http://commons.wikimedia.org/wiki/File:Coronary_heart_diseaseatherosclerosis.PNG
69.
National Cancer Institute. (1988, Dec.). Good food display.
Retrieved from
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
106
http://commons.wikimedia.org/wiki/File:Good_Food_Display__NCI_Visuals_Online.jpg
70.
Baird, M. (2008, Oct.). Runners at 1st annual Rock 2 Rock 5 Mile
Fun Run. Retrieved from
https://www.flickr.com/photos/mikebaird/2913348690/
71.
Wikipedia Commons. (2009, Feb.). Main symptoms of diabetes.
Retrieved from
http://en.wikipedia.org/wiki/Diabetes_mellitus#mediaviewer/File:Main
_symptoms_of_diabetes.png
72.
Padilla, M. (2007, Oct.). The gift of life. Retrieved from
https://www.flickr.com/photos/ladytaz/1836553797/
73.
Casale, V. (2013, Nov.). Diabetes test. Retrieved from
https://www.flickr.com/photos/49699516@N06/10871254373/
74.
Foster, K. (2011, Jun.). What now? Retrieved from
https://www.flickr.com/photos/61411590@N03/5859097301/
75.
Wikipedia Commons. (2009, Apr.). Depression: Loss of loved
one. Retrieved from
http://commons.wikimedia.org/wiki/File:Depressionloss_of_loved_one.jpg
76.
Mental Health America of Greater Houston. (2014, Apr.).
Veterans Initiative trains peer mentors. Retrieved from
http://www.mhahouston.org/photos/453/in/18/
77.
Peterson, B. (2010, Oct.). The meditation pond. Retrieved from
https://www.flickr.com/photos/50152666@N02/5107098600/
78.
Fox Valley Institute. (2011, Feb.). Cognitive therapy. Retrieved
from https://www.flickr.com/photos/87781710@N02/8343819455/
79.
Wikipedia Commons. (2012, Oct.). Gottesman’s multifactorial
model applied to alcohol abuse. Retrieved from
http://en.wikipedia.org/wiki/Irving_Gottesman
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
107
80.
Mott, D. (2009, Aug.). Anger management. Retrieved from
https://www.flickr.com/photos/vargklo/3882560446/
81.
Shen, R. (2007, Jul.). Group discussion time at the 4th section of
2007. Retrieved from
http://commons.wikimedia.org/wiki/File:GYSD_5th_Training_Day1_Se
c4_Group_Discussion.jpg
82.
National Cancer Institute. (2005, Dec.). Discussing cancer.
Retrieved from
http://commons.wikimedia.org/wiki/File:Discussing_cancer.jpg
83.
Search Engine People. (2009, Jun.). Conversation. Retrieved
from https://www.flickr.com/photos/38307206@N02/3676361977/
84.
Creative Commons. (2012, Jun.). 2012 Paris OER declaration.
Retrieved from http://creativecommons.org/tag/unesco
85.
Creative Commons. (2012, Jun.). Support grows for open access
to science research. Retrieved from
http://creativecommons.org/tag/open-access-policy
86.
Wikipedia. (2006, Jan.). A patient having his blood pressure
measured. Retrieved from
http://en.wikipedia.org/wiki/Primary_care_physician
87.
12Step.com. (2013). What is motivational interviewing?
Retrieved from http://www.12step.com/articles/sober-living/whatmotivational-interviewing
88.
Recovery.org. (2014). About the Alcoholics Anonymous (AA) 12-
step recovery program. Retrieved from
http://www.recovery.org/topics/alcoholics-anonymous-12-step/
ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com
108